DAPT Duration for High Bleeding Risk Patients After PCI

Nov 24, 2021
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Authors:
Valgimigli M, Cao D, Angiolillo DJ, et al., on behalf of the XIENCE 90 and XIENCE 28 Investigators.
Citation:
Duration of Dual Antiplatelet Therapy for Patients at High Bleeding Risk Undergoing PCI. J Am Coll Cardiol 2021;78:2060-2072.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • Patients at high bleeding risk undergoing DES implantation had less bleeding with 1 month vs. 3 months of DAPT.
  • Shorter-duration DAPT (1 month) was associated with similar rates of all-cause mortality and MI as 3-month DAPT.
  • Up to one-third of patients enrolled in this study underwent DES implantation for ACS.

Study Questions:

How do outcomes compare when patients receive 1 versus 3 months of dual antiplatelet therapy (DAPT) in high bleeding risk patients undergoing drug-eluting stent (DES) implantation?

Methods:

Patients from two single-arm studies were compared using propensity score analysis methods. From the XIENCE 28 study, patients received 1 month of DAPT followed by aspirin monotherapy after DES implantation. From the XIENCE 90 study, patients received 3 months of DAPT followed by aspirin monotherapy. Patients were followed for all-cause mortality, ischemic, and bleeding outcomes between 1 and 12 months.

Results:

A total of 3,652 patients were enrolled in the two single-arm studies. Patients experienced acute coronary syndromes (ACS) in 34-35% of patients in both treatment groups. The primary endpoint of all-cause mortality or myocardial infarction (MI) was similar between the 1- and 3-month DAPT groups (7.3% vs. 7.5%, p = 0.41). Bleeding (BARC 2-5) was lower in the 1-month DAPT arm as compared to the 3-month DAPT arm (7.6% vs. 10.0%, p = 0.012). Major bleeding (BARC 3-5) did not statistically differ at 12 months (3.6% vs. 4.7%, p = 0.082) but was lower at 90 days (1.0% vs. 2.1%, p = 0.015).

Conclusions:

The authors concluded that among patients at high bleeding risk undergoing DES implantation, 1 month of DAPT was associated with similar ischemic but lower bleeding outcomes as compared to 3 months DAPT.

Perspective:

Traditionally, many patients undergoing DES implantation have been recommended to receive 12 months of DAPT to prevent stent thrombosis. However, recent advances in stent technologies and a focus on reducing bleeding risk associated with multiple antithrombotic agents have led to numerous studies exploring the outcomes of shorter-duration DAPT therapy. This analysis of two single-arm, open-label studies compares outcomes for patients considered at high bleeding risk. In line with other similar studies, the patients receiving only 1 month of DAPT therapy showed fewer bleeding events than patients receiving 3 months of DAPT. Furthermore, both treatment groups experienced similar rates of all-cause mortality or MI. Importantly, approximately one-third of these patients underwent DES implantation in the setting of an ACS. For clinicians who are caring for patients at high bleeding risk but need DES implantation, short-term DAPT therapy (as short as 1 month) is a viable option to consider.

Clinical Topics: Acute Coronary Syndromes, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS

Keywords: Acute Coronary Syndrome, Aspirin, Drug-Eluting Stents, Fibrinolytic Agents, Geriatrics, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Patient Care, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, Thrombosis


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