One-Month Dual Antiplatelet Therapy Followed by Clopidogrel Monotherapy versus Standard 12-Month Dual Antiplatelet Therapy with Clopidogrel After Drug-Eluting Stent Implantation: Hirotoshi Watanabe Takenori Domei, Takeshi Morimoto, Hiroki Shiomi, Masahiro Natsuaki, Toshiaki Toyota, Kensuke Takagi, Yoshiki Hata, Satoru Suwa, Mamoru Nanasato, Masanobu Ohya, Masahiro Yagi, Takafumi Yokomatsu, Mitsuru Abe, Kenji Ando, Kazushige Kadota, Ken Kozuma, Yoshihiro Morino, Yuji Ikari, Kengo Tanabe, Koichi Nakao, Kazuya Kawai, Yoshihisa Nakagawa, and Takeshi Kimura, on behalf of STOPDAPT-2 investigators
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One-Month Dual Antiplatelet Therapy Followed by Clopidogrel Monotherapy
versus Standard 12-Month Dual Antiplatelet Therapy with Clopidogrel
Koichi Nakao, Kazuya Kawai, Yoshihisa Nakagawa, and Takeshi Kimura, on behalf of STOPDAPT-2 investigators
Background• Mandatory 1-month DAPT had been the standard care after BMS implantation.
• DAPT duration was prolonged after introduction of DES without firm scientific evidence.
• New generation DES has substantially reduced stent thrombosis.
• Prolonged DAPT is inevitably associated with increase in bleeding.
• Bleeding is associated with subsequent mortality risk at least comparable to that of MI.
• Therefore, very short mandatory DAPT duration after DES might be an attractive option, if not associated with increase in ischemic events disproportionate to the reduction in bleeding events.
STOPDAPTProspective multicenter open-label single arm trial
evaluating 3-month DAPT after CoCr-EES implantation
0%
10%
20%
0 180 360
Primary EndpointCardiovascular death, MI, Stroke, Definite ST, and Bleeding
2.8%4.0%
Adjusted HR 0.64 (0.42-0.95)P=0.03
STOPDAPTRESET
Days after PCI
Cum
ulat
ive
Inci
denc
e (%
)
Cardiovasc Interv Ther 2016; 31: 196–209.
Objective
The objective of the STOPDAPT-2 trial is to explore the
safety and efficacy of the experimental regimen of
1-month DAPT followed by clopidogrel monotherapy as
compared with the standard 12-month DAPT with aspirin
and clopidogrel after implantation of cobalt-chromium
Research Institute for Production Development, Kyoto, Japan
Saori TezukaYumika Fujino
Angiography Core Laboratory
Cardio Core Japan, Tokyo, Japan
Study administrative staff
Masahiro NatsuakiHirotoshi Watanabe
Toshiaki ToyotaToshikazu Jinnai
Funded by
Abbott Vascular Japan, Co., Ltd.
90 Participating CentersTeine Keijinkai HospitalHokko Memorial HospitalHirosaki University HospitalIwate Medical University HospitalSendai Kousei HospitalSendai Cardiovascular CenterTohoku Medical and Pharmaceutical University HospitalNakadori General HospitalNihonkai General HospitalHoshi General HospitalJichi Medical University HospitalMashiko HospitalMitsui Memorial HospitalJuntendo University HospitalThe Fraternity Memorial HospitalEdogawa HospitalShowa University Koto Toyosu HospitalTokyo Women's Medical University HospitalTokyo General HospitalJuntendo University Nerima HospitalKawakita General HospitalSakakibara Heart InstituteTokyo Metropolitan Tama Medical CenterMinamino Cardiovascular HospitalHigashiyamato HospitalSt.Marianna University School of Medicine HospitalYokohama Rosai HospitalShowa University Fujigaoka HospitalSaiseikai Yokohamashi Tobu HospitalYokohama City University Medical Center
Kitasato University HospitalHiratsuka Kyosai HospitalTokai University HospitalKimitsu Chuo HospitalKanazawa Cardiovascular HospitalUniversity of Fukui HospitalMunicipal Tsuruga HospitalUniversity of Yamanashi HospitalGifu Prefectural General Medical CenterOgaki Municipal HospitalJuntendo University Shizuoka HospitalShizuoka General HospitalJapanese Red Cross Nagoya Daini HospitalHanda City HospitalTosei General HospitalIchinomiyanishi HospitalYokkaichi Hazu Medical CenterMatsusaka Central General HospitalNabari City HospitalOtsu Red Cross HospitalHikone Municipal HospitalKyoto University HospitalKyoto Medical CenterMitsubishi Kyoto HospitalKitano HospitalOsaka Red Cross HospitalNational Cerebral and Cardiovascular CenterKindai University HospitalMimihara General HospitalBell Land General Hospital
Kobe City Medical Center General HospitalKindai University Nara HospitalTenri HospitalJapanese Red Cross Wakayama Medical CenterWakayama Medical University HospitalShimane University HospitalJapanese Red Cross Okayama HospitalKurashiki Central HospitalHiroshima University HospitalIwakuni Medical CenterTokuyama Central HospitalShimonoseki City HospitalTokushima University HospitalTokushima Red Cross HospitalKagawa Prefectural Central HospitalEhime Prefectural Central HospitalMatsuyama Red Cross HospitalChikamori HospitalKokura Memorial HospitalHospital of University of Occupational and Environmental Health JapanSaiseikai Fukuoka General HospitalFukuoka Tokushukai HospitalKumamoto University HospitalSaiseikai Kumamoto HospitalJapanese Red Cross Kumamoto HospitalMiyazaki Prefectural Nobeoka HospitalIbusuki Medical CenterIzumi Regional Medical CenterUrasoe General HospitalNakagami Hospital
Inclusion Criteria• PCI with exclusive use of CoCr-EES (XienceTM series) • No major complications during hospitalization for index PCI • No plan for staged PCI• Patients who could take DAPT with aspirin and P2Y12 inhibitors
Key Exclusion Criteria• Needs for oral anticoagulants • History of intracranial hemorrhage
Endpoints・ Primary endpoint:
Net adverse cardiovascular events (NACE: Ischemia and Bleeding)
・ A composite of cardiovascular death, MI, Definite ST, Stroke,
or TIMI major/minor bleeding
・ Major secondary endpoints:Ischemic composite endpoint
・ A composite of cardiovascular death, MI, Definite ST, or Stroke Bleeding endpoint
・ TIMI major/minor bleeding
Sample Size Calculation• Hypothesis: Non-inferiority of 1-month DAPT to 12-month DAPT
for the primary endpoint at 1-year
• Assumption: Event rate at 1-year: 4.6% (Based on RESET study).
• Non-inferiority margin; 50% on the hazard ratio scale
• Randomization ratio: 1:1
• One-sided alpha: 0.025
• Power: 85%
• Sample size: 3000 patients (1500 in each arm)
Study Flow
Enrolled and randomizedN=3045
Eligible patientsPCI exclusively with CoCr-EES/No scheduled staged PCI
Dec. 2015-Dec. 2017N=6504 3459 did not participate
• Lack of consensus on the use of the NACE as primary endpoint
• Open label design with its inherent limitations
• Limited enrollment of high ischemic risk patients
• Lower ischemic risk of Japanese versus US/European CAD patients
• Ticagrelor / Prasugrel (standard dose) not available in Japan
• No assessment of aspirin monotherapy after 1-month DAPT
Conclusions
One-month DAPT followed by clopidogrel monotherapy provided a net clinical benefit for ischemic and bleeding events over 12-month DAPT with aspirin and clopidogrel after CoCr-EES implantation.
The benefit was driven by significant reduction in bleeding events without increase in ischemic events.