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DAPT and Outcome After LM Bifurcation PCI
Study Questions:
What are the clinical outcomes after left main coronary artery (LM) bifurcation percutaneous coronary intervention (PCI) and the impact of the duration of dual antiplatelet therapy (DAPT) according to treatment strategy?
Methods:
The investigators conducted a patient-level pooled analysis of five nationwide multicenter registries. Rates of target lesion failure, thrombotic adverse cardiovascular events, and their individual components at 3 years were analyzed. Subgroup analysis according to DAPT duration was performed. Cumulative event rates were calculated based on Kaplan-Meier censoring estimates, and comparison of clinical outcomes was performed using the log-rank test. A multivariate Cox regression model was used to adjust for uneven distribution of baseline characteristics, and to identify independent predictors of the composite outcome.
Results:
From 13,172 patients undergoing PCI with new-generation drug-eluting stents, a total of 700 patients were treated for LM bifurcation lesions, 567 with a one-stent strategy, and 133 with a two-stent strategy. Rates of target lesion failure and target lesion revascularization were higher in the two-stent group, driven mainly by complex lesion profiles. Risks for thrombotic adverse cardiovascular events and its components were comparable between the two strategies. Subgroup analysis showed that risks for target lesion failure and thrombotic adverse cardiovascular events in the two-stent group were significantly higher than in the one-stent group in those with DAPT interruption <1 year, while they were similar in those receiving DAPT maintenance ≥1 year.
Conclusions:
The authors concluded that prolonged DAPT may be necessary when considering a two-stent strategy in LM PCI given its higher rate of repeat revascularization and lesion failure than the one-stent approach.
Perspective:
This pooled analysis of large-scale multicenter studies reports that a sizeable portion of patients with LM bifurcation lesions require PCI with a two-stent strategy in real-world practice. However, the two-stent strategy resulted in worse clinical outcomes compared with the one-stent strategy driven mainly by lesion complexity. Based on these data, interventionists, when faced with LM bifurcation lesions, need to be judicious in the decision to perform PCI, with coronary artery bypass grafting being the preferred option unless contraindicated. Moreover, when PCI with two stents is absolutely necessary or if the case ends up requiring a two-stent approach, maintenance of DAPT beyond 1 year may be important for outcome than in patients treated with one stent. Additional prospective studies are indicated to assess how different DAPT durations affect clinical outcomes with both one- and two-stent strategies for LM bifurcation lesions.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias
Keywords: Drug-Eluting Stents, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Secondary Prevention, Stents, Thrombosis
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