Dual anti platelet therapy duration where to draw the line

Dual Anti-Platelet Therapy
Duration
Where to draw the line?

Marvin H. Eng MD FSCAI FACC
Assistant Professor of Medicine
University of Texas Health Sciences Center
San Antonio, TX
Disclosures
• No relevant disclosures
DAPT-BMS era
30 Day Outcomes
0
1
2
3
4
5
1° Endpoint TLR Angiographic
thrombus
Recurrent MI
ASA
ASA + Warfarin
ASA + Ticlodipine
Leon MB et al. NEJM 1998;339:1665-71.
P=0.001
P=0.002
P=0.005
P=0.01

Clopidogrel in PCI
PCI-CURE
Mehta S et al. Lancet 2001;358:527-33.
DES Introduction
Stent Thrombosis
Trial

Stent

N

DAPT
Duration

ST
Rate (%)
SIRIUS

SES

1058

3 months

0.4%

TAXUS IV

PES

1314

6 months

0.6%

Moses JW et al. NEJM 2003;349:1315-23.
Stone GW et al. Circulation2004;109:1942-7.
Swiss DES Registry
BASKET-LATE
Pfisterer M et al. JACC 2006;48:2584-91.
DES
BMS
Outcomes of Early Stent Thrombosis
Definite or
Probable
ST %
Definite
ST %
Death

27.1

3.1

MI


QWMI

NQWMI
79.2


47.9

59.4
93.6


59.4

40.6
Unplanned
revascularization
66.7

96.9

Major Bleeding

14.6

12.5

Aoki J et al. Circulation 2009:119:687-698.
Stent Thrombosis
Early Thienopyridine Discontinuation
Iakovou I et al. JAMA 2005;293:2126-2130.
FDA Panel Analysis 2006

Laskey W et al. Circulation 2007;115:2352
DAPT
ASA and Thienopyridine Stopping
Eisenberg MJ et al. Circulation 2009;119:
1634-1642.
Cumulative Events (%)
Time from Antiplatelet Discontinuation to Late ST (Days)
DAPT Duration
Interruption vs. Disruption
Mehran R et al. Lancet 2013;382:1742-22.
ADAPT-DES
Incidence of ST according to ACS
STEMI

NSTEMI

UA
(no MI)
No ACS

P
-value
Overall

1.98%

1.59%

1.13%

0.80%

0.006

Early (0
-30d)
1.6%

0.57%

0.42%

0.22%

<0.001

Late (31d
-1yr)
0.25%

0.75%

0.48%

0.30%

0.14

V. Late (>1yr)

0.25%

0.67%

0.43%

0.22%

0.11

Kirtane, AJ TCT 2014, Washington D.C.
Definite Stent Thrombosis
Kyoto PCI/CABG Registry
Tada T. et al. Circulation Int. 2012;5:381-91.
DAPT
12 vs 24 months of DAPT (ZEST +REAL)
Park SJ et al. NEJM 2010;362:1374-82.
1° Combined Endpoint
Stent thrombosis
PRODIGY 6 month vs 24 months
Definite or probable ST at 24 months
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6

Late Very Late Cumulative
24 month
6 month
Valgimigli M et al. Circulation 2012;125:
2012-2026.
P= 0.82
P= 0.32
P= 0.7
Stent Thrombosis
1
st
Generation Stents
Nakazawa G et al. JACC 2011;57:390-8.
1
st
Generation Stents
Endothelialization
Nakazawa G et al. JACC 2011;57:390-8.
Stent Characteristics

Cypher

Taxus

Promus

Endeavor

Resolute

Xience

Platform

Bx

Velocity
Express/Li
berte

Element

Driver

Integrity

ML Vision

Architecture

Closed

Open

Open

Mod.
-
Open

Cont
-Open

Open

Alloy

316L

316L

Platinum

Chromium
Cobalt

Chromium
Cobalt

Chromium
Cobalt
Chromium
Strut

140
μm
132μm/9
7μm

81

μm

91
μm

91
μm

81
μm

Drug

Sirolimus

Paclitaxel

Everolimus

Zotarolimus

Zotarolimus

Everolimus

Polymer

PEVA/PMB
A

SIBS

Translute

VCF
-HFP
PC

Biolinx

VDF
-HFP
Kinetics

80% in
30d

10.2%10d
80%
30d
98% 14 d

85%
60d
80% 30d

Elution Time
168 d

Unknown

120
d
21
-22 d
180 d

120
d
Adapted from Eng MH and Kandzari DE.
E-ZES/EES
Neointimal Coverage
Kim SJ et al. Coronary Artery Disease 2013;
24:431-439
DAPT Duration
RESET- 3 month DAPT in E-ZES
Kim BK et al. JACC 2012;60:1340-8.
OPTIMIZE E-ZES
0-90 days
0
0.5
1
1.5
2
2.5
3
3.5
4
NACCE Major
Bleeding
Cardiac

Death
MACCE Stent
Thrombosis
3 Mo DAPT
12 Mo DAPT
Feres, F et al. JAMA 2013;310:2510-2522.
P=NS
OPTIMIZE E-ZES
91d-1yr
0
1
2
3
4
5
6
3 Mo DAPT
12 Mo DAPT
P=NS
Feres, F et al. JAMA 2013;310:2510-2522.
E-ZES (ZEUS)
ZES in non-ideal candidates
1 YR

ZES
n=802
BMS
n=804
HR
P-

value

MACE

17.5% 22.1%
0.76 (0.61
-
0.95)
0.011
TVR

5.9% 10.7%
0.53 (0.37
-
0.75)
<0.001
MI

2.9% 8.1%
0.35 (0.22
-
0.56)
<0.001
Definite/Pro
bable
ST
2.0% 4.1%
0.48 (0.27
-
0.88)

0.019
Valgimigli, M et al. AHJ 2013;166:831-8.
Valgimigli, M et al. ACC 2014, Washington D.C.
1 month DAPT d/c 43.6%
2 month DAPT d/c 62.5%
> 6 months DAPT 24.7%
E-ZES
OCT by 2 week interval
Nishinari, M et al. CCI 2013l82:E871-8.