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P2Y12 Inhibitor Monotherapy or DAPT After Complex PCI
Quick Takes
- The patient-level analysis from five randomized controlled trials examined the effect of P2Y12 inhibitor monotherapy (after 1 or 3 months of DAPT) vs. standard DAPT among patients with complex PCI (defined as any of six criteria: three vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with two stents implanted, total stent length >60 mm, or chronic total occlusion).
- Patients with complex PCI were at significantly greater risk of ischemic events and a numerically higher rate of bleeding than those receiving noncomplex PCI.
- P2Y12 inhibitor monotherapy after 1 or 3 months of DAPT was associated with a lower risk of bleeding with no significant differences in ischemic events compared to standard DAPT regardless of PCI complexity.
Study Questions:
What is the effect of P2Y12 inhibitor monotherapy after 1- to 3-month dual antiplatelet therapy (DAPT) versus standard DAPT in relation to percutaneous coronary intervention (PCI) complexity?
Methods:
The investigators pooled patient-level data from randomized controlled trials comparing P2Y12 inhibitor monotherapy and standard DAPT on centrally adjudicated outcomes after coronary revascularization. Complex PCI was defined as any of six criteria: three vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with two stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was all-cause mortality, myocardial infarction, and stroke. The key safety endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding.
Results:
Of 22,941 patients undergoing PCI from five trials, 4,685 (20.4%) with complex PCI had higher rates of ischemic events. The primary efficacy endpoint was similar between P2Y12 inhibitor monotherapy and DAPT among patients with complex PCI (hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.64-1.19) and noncomplex PCI (HR, 0.91; 95% CI, 0.76-1.09; p interaction = 0.770). The treatment effect was consistent across all the components of the complex PCI definition. Compared with DAPT, P2Y12 inhibitor monotherapy consistently reduced BARC 3 or 5 bleeding in complex PCI (HR, 0.51; 95% CI, 0.31-0.84) and noncomplex PCI patients (HR, 0.49; 95% CI, 0.37-0.64; p interaction = 0.920).
Conclusions:
P2Y12 inhibitor monotherapy after 1- to 3-month DAPT was associated with similar rates of fatal and ischemic events and lower risk of major bleeding compared with standard DAPT, irrespective of PCI complexity.
Perspective:
The current patient-level analysis from five randomized controlled trials examined the effect of P2Y12 inhibitor monotherapy (after 1 or 3 months of DAPT) versus standard DAPT among patients with complex PCI. Despite patients with complex PCI being at significantly greater risk of ischemic events and a numerically higher rate of bleeding than those receiving noncomplex PCI, P2Y12 inhibitor monotherapy after 1 or 3 months of DAPT was associated with a lower risk of bleeding with no significant differences in ischemic events compared to standard DAPT. Findings were consistent regardless of criteria used to define PCI complexity or type of P2Y12 inhibitor used. Although these findings add to existing data supporting shorter duration of DAPT regardless of PCI complexity, they require confirmation with randomized trials.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery
Keywords: Coronary Occlusion, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Receptors, Purinergic P2Y12, Risk, Stents, Stroke
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