Prolonged Antiplatelet Therapy Beneficial in Some After PCI

By David Douglas

NEW YORK - A subanalysis of the PRODIGY trial suggests that after percutaneous coronary intervention (PCI), extended dual antiplatelet therapy (DAPT) offers advantages to some but not all individuals, according to European investigators.

Overall, there was no clear benefit in favor of 24 months of DAPT over six months of therapy, Dr. Marco Valgimigli told Reuters Health by email. "There was also a worrisome signal indicating high bleeding liability in patients taking prolonged DAPT," he said.

In a presentation at the European Society of Cardiology Society Congress in Rome on August 30 and in a paper online in JAMA Cardiology, Dr. Valgimigli of Bern University Hospital, Switzerland, and colleagues compared outcomes in 246 patients with peripheral artery disease (PAD) and 1724 patients without PAD.

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Patients with PAD had a higher risk of death and ischemic events (hazard ratio, 2.80). For these patients, prolonged DAPT lowered the risk of the primary endpoint - a composite of death, myocardial infarction, or cerebrovascular accidents (HR, 0.54) - as well as the risk of definite or probable stent thrombosis (HR, 0.07)

In patients without PAD, however, prolonged DAPT increased the risk of reaching the primary endpoint (HR, 1.28).

Among patients with PAD, Academic Research Consortium type 2, 3, or 5 bleeding was seen in six who received prolonged DAPT and eight who received short DAPT (HR, 0.77).

"Our current analysis," Dr. Valgimigli continued, "supports the idea that patients with diffuse atherosclerosis (i.e., those with coronary as well as peripheral disease) derive an impressive benefit and no extra bleeding risk when treated with prolonged DAPT. We believe these are patients in whom the benefits outweigh the risks and should be offered a prolonged treatment."

He said the new findings, plus those of previous subanalyses his group has done, do not indicate "that two-year DAPT should be mainstream after coronary stent implantation but there are patient categories in whom this treatment strategy is beneficial including those with concomitant PAD, those treated for in-stent restenosis and those with acute coronary syndrome."

Commenting by email, Dr. Marc P. Bonaca of Brigham and Women's Hospital, Boston, author of an accompanying editorial, told Reuters Health that the subgroup analysis "provides important confirmatory evidence that peripheral artery disease is associated with further heightened ischemic risk in patients with a history of myocardial infarction."

"Both PEGASUS-TIMI 54 and PRODIGY (trials)," he added, "have now shown that this is a subgroup of MI patients that are likely to derive robust absolute risk reductions with more intensive antiplatelet therapy for long-term secondary prevention."

Dr. Bonaca concluded, "Future studies including PAD patients should also evaluate potential benefits in reducing limb ischemic outcomes as has now been shown with both ticagrelor and vorapaxar."

SOURCE: https://bit.ly/2cGRNzx and https://bit.ly/2cdqefk

JAMA Cardiol 2016.

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