Is one month DAPT enough for complex PCI?

Is one month DAPT enough for complex PCI?

Dual antiplatelet therapy (DAPT) is often a concern in those with high bleeding risk. But the risk of stent thrombosis is a nightmare for the interventional cardiologist after a percutaneous coronary intervention (PCI), especially after complex PCI. So, what is the way out? MASTER DAPT (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen) trial sub-analysis gives us some relief [1]. The analysis showed that high bleeding risk patients free from recurrent ischemic events at one month can consider discontinuation of DAPT.

In high bleeding risk patients, DAPT discontinuation in those free of recurrent ischemic events at one month was associated with similar NACE and MACCE and lower bleeding rates compared with standard DAPT, regardless of PCI or patient complexity. MACCE stands for major adverse cardiac or cerebral events and NACE for net adverse clinical events. NACE is a composite of all-cause death, myocardial infarction, stroke, and bleeding events.

1196 patients in the MASTER DAPT trial had undergone complex PCI which 3383 had undergone noncomplex PCI. The study had compared 1 month DAPT versus standard DAPT of 3 months or more in those with high bleeding risk. Patients received a biodegradable-polymer sirolimus-eluting stents. This was an investigator-initiated, randomized, open-label, noninferiority trial with sequential superiority testing. Patients were  randomized 30 to 44 days after the index procedure, if they remained uneventful till then.

Those randomly allocated to the shorter duration of DAPT immediately discontinued DAPT and continued single antiplatelet therapy until study completion. Those who were receiving oral anticoagulants continued single antiplatelet agents up to 6 months after the index procedure. Patients allocated to the standard treatment continued DAPT for at least 5 months, which would mean 6 months after the index procedure. Those receiving oral anticoagulants would receive DAPT for at least 2 additional months which would make it 3 months after the index procedure. Thereafter they were on single antiplatelet therapy.

The results of the MASTER DAPT trial sub-analysis is promising for those at high bleeding risk undergoing complex PCI. Let us hope that similar results will be documented by blinded trials as well soon.

Reference

1. Valgimigli M, Smits PC, Frigoli E, Bongiovanni D, Tijssen J, Hovasse T, Mafragi A, Ruifrok WT, Karageorgiev D, Aminian A, Garducci S, Merkely B, Routledge H, Ando K, Fernandez JFD, Cuisset T, Malik FTN, Halabi M, Belle L, Din J, Beygui F, Abhyankar A, Reczuch K, Pedrazzini G, Heg D, Vranckx P; MASTER DAPT Investigators. Duration of Antiplatelet Therapy After Complex Percutaneous Coronary Intervention In Patients at High Bleeding Risk: a MASTER DAPT trial sub-analysis. Eur Heart J. 2022 May 17:ehac284. doi: 10.1093/eurheartj/ehac284. Epub ahead of print. PMID: 35580836.