Choosing the Optimal Duration of DAPT in High Risk Bleeding Patients How to Decide? Rodrigo Bagur, MD, PhD, FAHA Interventional Cardiologist, Division of Cardiology University Hospital, London Health Sciences Centre Assistant Academic Professor, Department of Medicine Assistant Professor, Department of Epidemiology & Biostatistics Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
16
Embed
Choosing the Optimal Duration of DAPT in High Risk ...€¦ · against an increased risk of bleeding when continuing dual-antiplatelet therapy (DAPT) beyond 12 months The DAPT (Dual
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Choosing the Optimal Duration of DAPT in High Risk Bleeding Patients
How to Decide?
Rodrigo Bagur, MD, PhD, FAHAInterventional Cardiologist, Division of CardiologyUniversity Hospital, London Health Sciences CentreAssistant Academic Professor, Department of MedicineAssistant Professor, Department of Epidemiology & BiostatisticsSchulich School of Medicine & Dentistry, Western University, London, ON, Canada
Disclosures
➢ None.
➢ The optimal duration of aspirin plus a P2Y12 inhibitor for patients undergoing percutaneouscoronary intervention (PCI) for stable ischemic heart disease continues under debate
➢ The benefit of preventing myocardial infarction (MI) and stent thrombosis (ST) is balancedagainst an increased risk of bleeding when continuing dual-antiplatelet therapy (DAPT) beyond12 months
➢ The DAPT (Dual Antiplatelet Therapy) study1
✓ DAPT beyond 12 months after PCI with a drug-eluting stent (DES)✓ reduced the risks of ST and MACCE but ✓ increased risk of bleeding at 30 months compared to aspirin alone
Background
1Mauri L, et al. N Engl J Med. 2014;371(23):2155-66.
Case Presentation
➢ 84 yo Female
➢ Chronic Afib (CHADS2=3, CHA2DS2VASC=5) on Apixaban
➢ Failed Mitroflow 21-mm bioprosthetic AVR
➢ TAVI V-inV in 2016 with 20-mm SAPIEN-XT
➢ April 11th admitted with NSTEMI
➢ HS-Trop T 483 ng/L (normal ≤14)
➢ Creat 119 mg/dL (CrCl 32 mL/min)
➢ Hb 10.0 / LKC 6.7 / Plat 227
How do we define individuals that are at
high-risk of bleeding and ischemic events?
Clinical and Procedural Features Associated With Increased Ischemic or Bleeding Risk
Mehta SR, et al. Can J Cardiol. 2018;34:214-233.
Canadian Guidelines 2018ESC Guidelines 2017ACC/AHA Guidelines 2016
Levine GN, et al. JACC 2016;68(10):1082-1115.
Valgimigli M, et al. Eur Heart J. 2018;39(3):213-260.
Adapted from Mehta SR, et al. 2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol. 2018;34:214-233.
Cumulative Incidence of Endpoint Events From 12 to 30 Months After Randomization, Stratified by Treatment Arm, Anatomical Complexity, and DAPT Score
Complex Anatomy
Noncomplex Anatomy
Yeh RW, et al. JACC 2017;70(18):2213-23.
MY PATIENT
Complex PCI:✓ 3 stents implanted✓ ≥3 lesions treated✓ 3 coronary vessels treated✓ bifurcation with 2 stents implanted✓ total stent length >60 mm, and/or✓ treatment of a chronic total occlusion
Risk difference for long-term versus short-term DAPT duration stratified by PRECISE-DAPT Score and Complex PCI Anatomy
Costa F, et al. J Am Coll Cardiol. 2019;73(7):741–54.
MY PATIENT
Giustino and Costa. JACC Interv 2019;12(9):831-4
Balancing the risk of bleeding and in ischemic events
MY PATIENT
✓ 1 month triple therapy with ASA 81 mg OD plus clopidogrel 75 mg OD plus apixaban 5 mg BID plus pantoprazole 40 mg OD
✓ clopidogrel plus apixaban to complete 12 months
✓ apixaban indefinitely
➢ The DAPT score is a useful tool to determine a prolonged (12-30 months) duration of DAPT in patients at high ischemic risk
➢ The PRECISE-DAPT score is a useful tool to determine a short (1, 3 or 6 months) duration of DAPT in patients at high bleeding risk
➢ The decision to prescribe a short-term DAPT or continue it after 12 months, should be an individualized decision for each patient (personalized medicine)