DAPT after left main stentingNguyen Quoc Thai, MD, PhD, FASCC

Vietnam National Heart Institute

Dec. 15 2019, 6TH SCIENTIFIC CONFERENCE OF HCMC HEART INSTITUTE

Timeline of myocardial revascularization in left main coronary artery disease

Collet C. et al. Nat Rev Cardiol15, 321–331 (2018) doi:10.1038/s41569-018-0001-4

Timeline of antiplatelet therapy after percutaneous coronary intervention

Yosuke Miyazaki et al. Nature Reviews Cardiology volume 14, pages 294–303(2017)

Oviedo et al. Circ Cardiovasc Interv. 2010;3;105-12

IVUS plaque distribution in 140 distal

LMCA birfucations

90% LAD/LCx to LMCA10% distal LMCA

PCi bifurcation techniques for patients with unprotected left main CAD

Collet C. et al. Nat Rev Cardiol15, 321–331 (2018) doi:10.1038/s41569-018-0001-4

EXCEL trial: Five-Year Outcomes after PCI or CABG for Left Main CAD

Stone GW et al. N Engl J Med 2019; 381:1820-1830. DOI: 10.1056/NEJMoa1909406

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PCI in Patients Complexity

Neumann et al. European Heart Journal (2018) 00, 1–96 ESC/EACTS GUIDELINES

High-risk clinical and angiographic features for thrombotic events

Left main or proximal LAD identifies high-risk patients deriving potentially greater benefit from prolonged DAPT duration

Costa F, Adamo M, Ariotti S, et al. Eurointervention 2016;11:e1222-30.

Guy Witberg et al., European Heart Journal - Cardiovascular Pharmacotherapy (Dec 7 2019), , pvz075, https://doi.org/10.1093/ehjcvp/pvz075

Meta-Analysis of Studies Examining the External Validity of the DAPT Score Seven studies (77,274 patients)

Main results•High DAPT score (≥2) was associated with increased risk for MI/ST (OR 1.54, 95%CI 1.41-1.69, P<0.01, I²=45%, 7 studies, n=77,274) and reduced risk for bleeding (OR 0.84, 95%CI 0.73-0.97, P=0.01 I²=0%, 7 studies, n=77272).•In the high DAPT score stratum (≥2), extended as compared to standard DAPT duration was associated with lower risk for MI/ST (OR 0.67, 95% CI 0.48-0.94, P=0.02 I²=0%, 4 studies, n=6,173), and no increase in bleeding risk (OR 1.04, 95% CI 0.65-1.66, P=0.88 I²=0%, 4 studies, n=6,173).•In the low DAPT score stratum (<2), extended DAPT duration was associated with no difference in risk for MI/ST (OR 1.04, 95% CI 0.76-1.43, P=0.80 I²=24%, 4 studies, n=9,948), and increased risk for bleeding (OR 1.58, 95% CI 1.15-2.15, P<0.01 I²=5%, 4 studies, n=9,948).

ConclusionThis meta-analysis of the efficacy and safety of extended vs standard DAPT in post PCI patients stratified by DAPT score strata, suggests that the DAPT score is useful for stratifying patients into risk strata for ischemic and bleeding events, and for the choice of DAPT duration. For patients with a high DAPT score, extended DAPT duration resulted in reduced ischemic risk with no increase in bleeding risk. For low DAPT score patients, extended therapy led to no difference in ischemic risk, but increased risk for bleeding.

Brener SJ et al. JACC VOL. 72, NO. 17, 2018 OCTOBER 23, 2018:2086–94

Optimal Duration of Dual Antiplatelet Therapy After Left Main Coronary Stenting

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 24, 2018 DECEMBER 24, 2018:2453–63

Study Flow Chart

Rhee TM, Park KW, Kim CH, et al. J Am Coll Cardiol Intv 2018;11:2453–63

Clinical Outcomes According to Treatment Strategies Stratified by Duration of Dual Antiplatelet Therapy

Target lesion failure: cardiac death, target vessel MI, or clinically driven TLR Thrombotic adverse cardiovascular events: cardiac death, any MI, or definite or probable ST

Rhee TM, Park KW, Kim CH, et al. J Am Coll Cardiol Intv 2018;11:2453–63

A considerable proportion of patients with LM bifurcation lesions require PCI with a 2-stent strategy in real-world practice. Although the 2-stent strategy was as safe as the 1-stent approach with the use of new- generation DES, careful preemptive case selection and DAPT maintenance >1 year may be necessary for the 2-stent approach, given its higher rate of repeat revascularization and other clinical outcomes compared with the 1-stent approach.

CONCLUSIONS

Rhee TM, Park KW, Kim CH, et al. J Am Coll Cardiol Intv 2018;11:2453–63

Cho S et al. American Journal of Cardiology. 2019 Nov 7. pii: S0002-9149(19)31233-0. doi: 10.1016/j.amjcard.2019.10.046.

Long-Term Efficacy of Extended Dual Antiplatelet Therapy after Left Main Coronary Artery Bifurcation Stenting

Korean Multicenter Angioplasty Team (KOMATE) , Coronary Bifurcation Stenting (COBIS) II registries: 1,142 LMCA bifurcation stenting patients

Independent Predictors of Clinical Outcomes

Cho S et al. American Journal of Cardiology. 2019 Nov 7. pii: S0002-9149(19)31233-0. doi: 10.1016/j.amjcard.2019.10.046.

Take home message

• PCI in LM is high risk intervention• DAPT after LM stenting: potent P2Y12 inhibitor, long duration of DAPT

exception HBR patients• Timing of duration DAPT after LM stenting is not clearly and debating

“the longer the DAPT, the better the outcome”

“As time goes by”1942 Cansablanca Film