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Choosing the Optimal Duration of DAPT in High Risk Bleeding Patients How to Decide?

Explore the optimal duration of dual antiplatelet therapy (DAPT) in high-risk bleeding patients post-PCI. Learn when to extend or shorten DAPT based on individualized risks and scores. Take-home message for personalized medicine.

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Choosing the Optimal Duration of DAPT in High Risk Bleeding Patients How to Decide?

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  1. Choosing the Optimal Duration of DAPT in High Risk Bleeding Patients How to Decide? Rodrigo Bagur, MD, PhD, FAHAInterventional Cardiologist, Division of Cardiology University Hospital, London Health Sciences CentreAssistant Academic Professor, Department of Medicine Assistant Professor, Department of Epidemiology & Biostatistics Schulich School of Medicine & Dentistry, Western University, London, ON, Canada

  2. None. Disclosures

  3. Background • The optimal duration of aspirin plus a P2Y12 inhibitor for patients undergoing percutaneous coronary intervention (PCI) for stable ischemic heart disease continues under debate • The benefit of preventing myocardial infarction (MI) and stent thrombosis (ST) is balanced against an increased risk of bleeding when continuing dual-antiplatelet therapy (DAPT) beyond 12 months • The DAPT (Dual Antiplatelet Therapy) study1 • DAPT beyond 12 months after PCI with a drug-eluting stent (DES) • reduced the risks of ST and MACCE but • increased risk of bleeding at 30 months compared to aspirin alone 1Mauri L, et al. N Engl J Med. 2014;371(23):2155-66. 

  4. Case Presentation • 84 yo Female • Chronic Afib (CHADS2=3, CHA2DS2VASC=5) on Apixaban • Failed Mitroflow 21-mm bioprosthetic AVR • TAVI V-inV in 2016 with 20-mm SAPIEN-XT • April 11th admitted with NSTEMI • HS-Trop T 483 ng/L (normal ≤14) • Creat 119 mg/dL (CrCl 32 mL/min) • Hb 10.0 / LKC 6.7 / Plat 227

  5. How do we define individuals that are at high-risk of bleeding and ischemic events?

  6. Clinical and Procedural Features Associated With Increased Ischemic or Bleeding Risk ACC/AHA Guidelines 2016 ESC Guidelines 2017 Canadian Guidelines 2018 Valgimigli M, et al. Eur Heart J. 2018;39(3):213-260. Mehta SR, et al. Can J Cardiol. 2018;34:214-233. Levine GN, et al. JACC 2016;68(10):1082-1115.

  7. Predicting the risk of ischemic and bleeding events Adapted from Mehta SR, et al. 2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol. 2018;34:214-233.

  8. Unprotected Left main PCI: Summary • Right ulnar access, 6Fr sheath • XB 3.0 6Fr guide catheter • 2 wires • Predilation both arms with standard balloons then NC • 2-stent strategy = “T-stenting” • Kissing balloon inflation • Final POT in LM • 3.5x18 mm Everolimus • Eluting Stent • ostial LM-prox LAD 3.0x15 mm Everolimus Eluting Stent ostial-proxCx

  9. Predicting the risk of ischemic and bleeding events Adapted from ESC Guidelines 2017. Valgimigli M, et al. Eur Heart J. 2018;39(3):213-260.

  10. http://tools.acc.org/DAPTriskapp/#!/content/calculator/ MY PATIENT

  11. http://www.precisedaptscore.com/predapt/webcalculator.html MY PATIENT

  12. How do we define the complexity of coronary anatomy?

  13. Cumulative Incidence of Endpoint Events From 12 to 30 Months After Randomization, Stratified by Treatment Arm, Anatomical Complexity, and DAPT Score Complex Anatomy Noncomplex Anatomy MY PATIENT Yeh RW, et al. JACC 2017;70(18):2213-23.

  14. Risk difference for long-term versus short-term DAPT duration stratified by PRECISE-DAPT Score and Complex PCI Anatomy • Complex PCI: • 3 stents implanted • ≥3 lesions treated • 3 coronary vessels treated • bifurcation with 2 stents implanted • total stent length >60 mm, and/or • treatment of a chronic total occlusion MY PATIENT Costa F, et al. J Am Coll Cardiol. 2019;73(7):741–54.

  15. Balancing the risk of bleeding and in ischemic events MY PATIENT • 1 month triple therapy with ASA 81 mg OD plus clopidogrel 75 mg OD plus apixaban 5 mg BID plus pantoprazole 40 mg OD • clopidogrel plus apixaban to complete 12 months • apixaban indefinitely Giustino and Costa. JACC Interv 2019;12(9):831-4

  16. Take-home message • The DAPT score is a useful tool to determine a prolonged (12-30 months) duration of DAPT in patients at high ischemic risk • The PRECISE-DAPT score is a useful tool to determine a short (1, 3 or 6 months) duration of DAPT in patients at high bleeding risk • The decision to prescribe a short-term DAPT or continue it after 12 months, should be an individualized decision for each patient (personalized medicine)

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