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1- or 3-Month DAPT in Patients With Oral Anticoagulation After PCI
Quick Takes
- Dual antiplatelet therapy (DAPT) for 1 vs. 3 months after PCI was associated with a similar adjusted risk of death or MI and a consistent reduction of BARC 2-5 bleeding in both oral anticoagulation (OAC) and no-OAC groups.
- These data suggest that 1-month DAPT followed by aspirin monotherapy might be a suitable option in high bleeding risk (HBR) patients at low ischemic risk, especially if on long-term OAC treatment to maximize bleeding protection without trade-off of ischemic events.
- Additional randomized studies are indicated to assess the most appropriate timing of early DAPT discontinuation after PCI and which agent (aspirin vs. P2Y12 inhibitor) should be continued in HBR patients taking OAC.
Study Questions:
What are the effects of 1- versus 3-month dual antiplatelet therapy (DAPT) in patients with and without concomitant oral anticoagulation (OAC) included in the XIENCE Short DAPT program?
Methods:
The investigators used data from the XIENCE Short DAPT program, which enrolled high bleeding risk (HBR) patients who underwent successful percutaneous coronary intervention (PCI) with a cobalt-chromium everolimus-eluting stent. This analysis was designed to compare the effect of 1- versus 3-month DAPT on clinical outcomes separately in patients with and without long-term OAC. DAPT was discontinued at 1 or at 3 months in patients free from ischemic events and adherent to treatment. The effect of 1- versus 3-month DAPT was compared in patients with and without OAC using propensity score stratification. The primary endpoint was all-cause death or any myocardial infarction (MI). The key secondary endpoint was Bleeding Academic Research Consortium (BARC) type 2-5 bleeding. Outcomes were assessed from 1 to 12 months after index PCI.
Results:
Out of 3,364 event-free patients, 1,462 (43%) were on OAC. Among OAC patients, the risk of death or MI was similar between 1- and 3-month DAPT (7.4% vs. 8.8%; adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.49-1.11; p = 0.139), whereas BARC 2-5 bleeding was lower with 1-month DAPT (aHR, 0.71; 95% CI, 0.51-0.99; p = 0.046). These effects were consistent in patients with or without OAC (p for interaction = nonsignificant).
Conclusions:
The authors report that between 1 and 12 months after PCI, 1- compared with 3-month DAPT was associated with a similar rate of all-cause death or MI and a reduced rate of BARC 2-5 bleeding, irrespective of OAC treatment.
Perspective:
This subgroup analysis from the XIENCE Short DAPT program reports that 1- compared with 3-month DAPT after PCI was associated with a similar adjusted risk of death or MI and a consistent reduction of BARC 2-5 bleeding in both OAC and no-OAC groups. Of note, the study population was mostly at low risk of ischemic events, since patients with ST-segment elevation MI or some complex PCI features were excluded. Overall, these data suggest that 1-month DAPT followed by aspirin monotherapy might be a suitable option in HBR patients at low ischemic risk, especially if on long-term OAC treatment to maximize bleeding protection without trade-off of ischemic events. Given several limitations of the current analysis, additional randomized studies are indicated to assess the most appropriate timing of early DAPT discontinuation after PCI and which agent (aspirin vs. P2Y12 inhibitor) should be continued in HBR patients taking OAC.
Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention
Keywords: Anticoagulants, Hemorrhage, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors
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