Efficacy and Safety of Dual Antiplatelet Therapy After Complex PCI.
Optimal upfront dual antiplatelet therapy (DAPT) duration after complex percutaneous coronary intervention (PCI) with drug-eluting stents (DES) remains unclear.



This study investigated the efficacy and safety of long-term (≥12 months) versus short-term (3 or 6 months) DAPT with aspirin and clopidogrel according to PCI complexity.



The authors pooled patient-level data from 6 randomized controlled trials investigating DAPT durations after PCI. Complex PCI was defined as having at least 1 of the following features: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction, or stent thrombosis. The primary safety endpoint was major bleeding. Intention-to-treat was the primary analytic approach.



Of 9,577 patients included in the pooled dataset for whom procedural variables were available, 1,680 (17.5%) underwent complex PCI. Overall, 85% of patients received new-generation DES. At a median follow-up time of 392 days (interquartile range: 366 to 710 days), patients who underwent complex PCI had a higher risk of MACE (adjusted hazard ratio [HR]: 1.98; 95% confidence interval [CI]: 1.50 to 2.60; p < 0.0001). Compared with short-term DAPT, long-term DAPT yielded significant reductions in MACE in the complex PCI group (adjusted HR: 0.56; 95% CI: 0.35 to 0.89) versus the noncomplex PCI group (adjusted HR: 1.01; 95% CI: 0.75 to 1.35; pinteraction= 0.01). The magnitude of the benefit with long-term DAPT was progressively greater per increase in procedural complexity. Long-term DAPT was associated with increased risk for major bleeding, which was similar between groups (pinteraction= 0.96). Results were consistent by per-treatment landmark analysis.



Alongside other established clinical risk factors, procedural complexity is an important parameter to take into account in tailoring upfront duration of DAPT.
The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Cardiovascular Research Foundation, New York, New York; San Raffaele Scientific Institute, Interventional Cardiology Unit, Milan, Italy.
Gennaro
G
Giustino
San Raffaele Scientific Institute, Interventional Cardiology Unit, Milan, Italy. Electronic address: chieffo.alaide@hsr.it.
Alaide
A
Chieffo
Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy.
Tullio
T
Palmerini
Erasmus Medical Center, Thoraxcenter, Rotterdam, the Netherlands.
Marco
M
Valgimigli
Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
Fausto
F
Feres
Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
Alexandre
A
Abizaid
Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
Ricardo A
RA
Costa
Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea.
Myeong-Ki
MK
Hong
Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea.
Byeong-Keuk
BK
Kim
Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea.
Yangsoo
Y
Jang
Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
Hyo-Soo
HS
Kim
Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
Kyung Woo
KW
Park
Department of Cardiology, Brest University, Brest, France.
Martine
M
Gilard
Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France.
Marie-Claude
MC
Morice
Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France.
Fadi
F
Sawaya
Department of Cardiovascular, Respiratory, Nephrologic and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy.
Gennaro
G
Sardella
Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Philippe
P
Genereux
Cardiovascular Research Foundation, New York, New York.
Bjorn
B
Redfors
San Raffaele Scientific Institute, Interventional Cardiology Unit, Milan, Italy; Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Martin B
MB
Leon
Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
Deepak L
DL
Bhatt
Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York.
Gregg W
GW
Stone
San Raffaele Scientific Institute, Interventional Cardiology Unit, Milan, Italy.
Antonio
A
Colombo
D001241:Aspirin / Q000008:administration & dosage* / Q000009:adverse effects; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D011183:Postoperative Complications / Q000139:chemically induced / Q000453:epidemiology / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
bleeding; drug-eluting stents; myocardial infarction; stent thrombosis