Читать книгу Interventional Cardiology - Группа авторов - Страница 302

Optimal DAPT duration after PCI for NSTE‐ACS remains controversial. In the past extra‐long antiplatelet regiments were considered the norm to prevent thrombotic events, especially for ACS patients. In the era of new generation DES, shorter DAPT duration is being evaluated. Risk stratification tools, such as the PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti Platelet Therapy (PRECISE‐DAPT) score may help towards that direction [45]. The most recent guideline recommendations on DAPT duration from Europe and the United States are presented in Figure 12.3 [46,47].

Figure 12.3 American and European guidelines on optimal DAPT duration in ACS patients.

ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; HBR, high bleeding risk; MI, myocardial infarction.

In the Short and Optimal Duration of Dual Antiplatelet Therapy After Everolimus‐Eluting Cobalt‐Chromium Stent (STOPDAPT‐2) trial 1 month of DAPT followed by clopidogrel monotherapy compared to 12 months of DAPT demonstrated non‐inferiority as well as superiority for the primary endpoint of cardiovascular death, MI, ischemic or hemorrhagic stroke, definite stent thrombosis, or major or minor bleeding at 12 months. More importantly, the major secondary endpoint of cardiovascular death, MI, ischemic or hemorrhagic stroke, or definite stent thrombosis was not different between the two groups (1.96% vs 2.51%; p‐value=0.34, pnon‐inferiority= 0.005). However, of the 3045 patients enrolled in this trial, only 587 (19.5%) presented with an NSTE‐ACS [48]. Concurrently, the Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug‐Eluting Stents (SMART‐CHOICE) trial randomized 2993 patients (47.7% NSTE‐ACS) to 3 months of DAPT and 9 months of P2Y12 inhibitor monotherapy versus the conventional 12 months of DAPT. The experimental arm achieved a statistically significant lower rate of bleeding type 2 to 5 according to Bleeding Academic Research Consortium (2.0% vs 3.4%; P = 0.02) and was non‐inferior for the primary endpoint of all‐cause death, myocardial infarction, or stroke at 1 year. (2.9% vs 2.5%; pnon‐inferiority= 0.007) [49]. The largest trial to date (n=7,487) the Clinical Study Comparing Two Forms of Anti‐platelet Therapy After Stent Implantation (GLOBAL LEADERS) failed to show that 1 month of aspirin plus ticagrelor followed by 23 months of ticagrelor monotherapy was superior to 1 year of dual antiplatelet therapy (DAPT) (aspirin plus either clopidogrel or ticagrelor) followed by 1 year of aspirin monotherapy for preventing adverse events among patients undergoing percutaneous coronary intervention (PCI) with a biolimus‐eluting stent [50].

The Ticagrelor with Aspirin or Alone in High‐Risk Patients after Coronary Intervention (TWILIGHT) trial enrolled 7119 high risk patients across 11 countries and randomized them to a conventional regiment of 12 months of DAPT with ticagrelor versus 3 months of DAPT followed by P2Y12 inhibitor monotherapy with ticagrelor. TWILIGHT reported lower bleeding (7.1% vs 4.0%; P<0.001) with no apparent ischemic harm (3.9% vs 3.9%; p for non‐inferiority <0.001) with monotherapy. The outcome was consistent across the stable CAD and NSTE‐ACS (35% of patients had unstable angina and 30% had NSTEMI ) subgroups [51]. In summary, a short DAPT regiment followed by P2Y12 monotherapy may be an appealing post‐PCI regiment, especially for patients at high bleeding risk [52].