Log in to MyACC
PRECISE-DAPT Score and Complex PCI
Study Questions:
What are the effects of ischemic (by percutaneous coronary intervention [PCI] complexity) and bleeding (by PRECISE-DAPT score) risks on clinical outcomes and on the impact of dual antiplatelet therapy (DAPT) duration after coronary stenting?
Methods:
The study population consisted of 14,963 patients treated with PCI and subsequent DAPT. In brief, patients treated with coronary stenting in an elective, urgent, or emergent setting were pooled at an individual level from eight randomized controlled trials. The duration of DAPT with aspirin and a P2Y12 inhibitor was randomly assigned to short- (3 or 6 months) or long-term (12 or 24 months) treatment in 10,081 patients in five of the eight included studies, whereas the duration lasted according to international guidelines in two studies, and ranged from 1 to 12 months based on patient characteristics in one study. Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or nonhigh (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. The absolute risk difference (ARD) and its 95% confidence interval (CI) were calculated according to Altman et al.
Results:
Among 14,963 patients from eight randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non–high bleeding risk (HBR) patients reduced ischemic events in both complex (ARD, -3.86%; 95% CI, -7.71 to +0.06) and noncomplex PCI strata (ARD: -1.14%; 95% CI, -2.26 to -0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity.
Conclusions:
The authors concluded that patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present.
Perspective:
This study reports that patients with HBR had a higher incidence of both bleeding and ischemic events, including mortality, compared with non-HBR patients. Patients who did not fulfill HBR criteria had a consistent benefit from long-term DAPT compared with that of short-term DAPT, with no apparent tradeoff in bleeding. However, HBR patients did not derive ischemic or mortality benefit from long-term DAPT, regardless of the complexity of the intervention they underwent or the acute presentation at the time of PCI. Prospective studies are needed to verify whether patients at HBR derive net benefit from a shorter duration of DAPT after stenting, regardless of procedural complexity.
Keywords: Aspirin, Coronary Occlusion, Hemorrhage, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Secondary Prevention, Risk Assessment, Stents
< Back to Listings
