One-month DAPT sufficient after PCI?

Two separate analyses presented at SCAI 2021 demonstrated that a 1-month dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) appears to be safe and effective for PCI patients at high risk of bleeding (ie, those with advanced age, chronic NSAID use, bleeding history, anaemia, thrombocytopenia, etc), compared with a DAPT regimen between 6 and 12 months.

Different cardiovascular conditions require different durations of DAPT after PCI, as per the current ACC/AHA/SCAI* guidelines. For stable ischemic heart disease, the recommend duration is 6 months, while for acute coronary syndrome, the recommended duration is 12 months, noted Dr Raahat Bansal from the CHI Health Creighton University Medical Center, Omaha, Nebraska, US, in his poster presentation.

Also, these guidelines postulate that it is reasonable to stop DAPT after 3 months in PCI patients with high bleeding risk, added Bansal.

To ascertain the appropriate minimum duration of DAPT after PCI with DES, a meta-analysis pooled three large randomized trials – GLOBAL LEADERS, STOPDAPT2, and One-Month DAPT – comparing a 1-month against a 6–12-month DAPT regimen (n=10,987 and 11,010, respectively). [SCAI 2021, poster F1]

At 1-year follow-up, despite the lack of statistical significance, the 1-month DAPT regimen outdid the 6–12-month strategy, as reflected by the lower rates of all-cause mortality (risk ratio [RR], 0.84, 95 percent confidence interval [CI], 0.67–1.05; p=0.13), any bleeding (RR, 0.63, 95 percent CI, 0.37–1.05; p=0.08), stroke (RR, 0.87, 95 percent CI, 0.59–1.29; p=0.48), and target vessel revascularization (TVR; RR, 0.90, 95 percent CI, 0.77–1.04; p=0.16) associated with the former vs the latter arm.

Conversely, the findings appear to favour the longer vs the shorter DAPT regimen in terms of 1-year rates of definite stent thrombosis (RR, 1.29, 95 percent CI, 0.89–1.88; p=0.18) and myocardial infarction (MI; RR, 1.10, 95 percent CI, 0.90–1.33; p=0.35).

Another analysis pooled data from the ONYX ONE, ONYX ONE US/Japan, and ZEUS trials (n=2,385; mean age 73 years), which looked into outcomes of a 1-month DAPT regimen following PCI using a polymer-based DES among individuals with high bleeding risk. [SCAI 2021, poster F2]

At 1 year, the pooled incidences for all-cause mortality was 7.9 percent (95 percent CI, 0.051–0.119; p=0.00). “[This reflects] acceptable rates of 1-year mortality in this high-risk population,” Bansal said.

For MI and BARC** 2-5 bleeding, the incidences were 6.3 percent (95 percent CI, 0.025–0.150; p=0.00) and 11.2 percent (95 percent CI, 0.061–0.197; p=0.00), respectively.

Moreover, Bansal noted that the rates of definite stent thrombosis, stroke, and TVR are low at 0.9 percent (95 percent CI, 0.006–0.014; p=0.95), 1.6 percent (95 percent CI, 0.010–0.025; p=0.16), and 5.0 percent (95 percent CI, 0.037–0.067; p=0.06), respectively.

“[Taken together,] our analyses suggest that discontinuation of DAPT after 1 month is a safe and effective strategy after PCI, particularly in patients with high bleeding risk,” Bansal concluded.