Association Between Duration of Dual Antiplatelet Therapy and Angiographic Multivessel Disease on Outcomes in Patients Treated With Newer-Generation Drug-Eluting Stents.
There is general agreement that the optimal duration of dual antiplatelet therapy (DAPT) in patients treated with drug-eluting stents should be individualized. We hypothesized that the extent of coronary artery disease may affect the clinical outcomes of DAPT.



We pooled patient-level data from 5 large, randomized trials comparing short-term DAPT with prolonged therapy. From the data, we identified 5476 patients who received newer-generation drug-eluting stents. Net adverse clinical event (NACE) was defined as a composite of all-cause mortality, myocardial infarction, stroke, or major bleeding. At 1 year, NACE had occurred in 171 patients (3.1%). Independent predictors of NACE were older age (>65 years), sex, presence of diabetes mellitus, left ventricular dysfunction (ejection fraction <40%), and angiographic multivessel disease. Multivessel disease and DAPT duration were significantly associated with NACE (P for interaction=0.002); the association was driven by the greater occurrence of myocardial infarction in patients with multivessel disease. In patients with multivessel disease, 6-month DAPT (versus 12-month DAPT) was associated with a higher incidence of myocardial infarction (adjusted hazard ratio=2.748; 95% confidence interval=1.375-5.491; P=0.004), compared with patients with single-vessel disease (P for interaction=0.001).



In patients treated with newer-generation drug-eluting stents, a significant interaction between DAPT strategy and multivessel disease was found regarding the occurrence of NACE at 1 year. Among adverse events, myocardial infarction was more frequent in 6-month DAPT than in 12-month DAPT in patients with multivessel disease.
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Seung-Yul
SY
Lee
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.). mkhong61@yuhs.ac.
Myeong-Ki
MK
Hong
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Dong-Ho
DH
Shin
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Jung-Sun
JS
Kim
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Byeong-Keuk
BK
Kim
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Young-Guk
YG
Ko
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Donghoon
D
Choi
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Yangsoo
Y
Jang
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Hyo-Soo
HS
Kim
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Marco
M
Valgimigli
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Antonio
A
Colombo
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Martine
M
Gilard
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Tullio
T
Palmerini
From the Department of Internal Medicine, Sanbon Hospital, Wonkwang University College of Medicine, Gunpo, Korea (S.-Y.L.); Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.); Cardiovascular Research Institute (M.-K.H., D.-H.S., J.-S.K., B.-K.K., Y.-G.K., D.C., Y.J.) and Severance Biomedical Science Institute (M.-K.H., Y.J.), Yonsei University College of Medicine, Seoul, Korea; Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.); Department of Cardiology, Bern University Hospital, Switzerland (M.V.); Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy (A.C.); Department of Cardiology, CHU de la Cavale Blanche, Brest, France (M.G.); Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy (T.P.); and Columbia University Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, NY (G.W.S.).
Gregg W
GW
Stone
D000368:Aged; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors
antiplatelet drugs; coronary artery disease; drug-eluting stent