Skip to main content

Advertisement

SpringerLink
Log in

Impact of Prolonged Dual Antiplatelet Therapy After Bifurcation Percutaneous Coronary Intervention in Patients with High Ischemic Risk

  • Original Research Article
  • Published:
American Journal of Cardiovascular Drugs Aims and scope Submit manuscript

Abstract

Background

The aim of this study was to evaluate the impact of prolonged dual antiplatelet therapy (DAPT) on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI) for bifurcation coronary lesions.

Methods

A total of 1000 patients who underwent PCI for coronary bifurcation lesions and had clinical follow-up were divided into two groups based on the duration of DAPT: DAPT > 12 months and DAPT ≤ 12 months). Patients who experienced a myocardial infarction, required repeat PCI, or died within 1 year after the initial procedure were excluded.

Results

Among the 1000 eligible patients, 394 patients received DAPT for > 12 months (39.4%). Most patients in our study presented with chronic coronary disease (61%). The majority of patients in our study (62.8%) had a low bleeding risk. The median follow-up duration was 35 months (interquartile range 20.6–36.5). There were no significant differences in the major adverse cardiovascular events (MACE) between groups of prolonged DAPT (> 12 month) and DAPT ≤ 12 months (18.8% vs. 14.9%, p = 0.11). Patients with clinical features of high ischemic risk (HIR) had a significantly increased risk of MACE (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12–3.26, p = 0.015) when compared with patients without clinical features of HIR. Compared with DAPT ≤ 12 months, extended DAPT (> 12 months) did not improve outcomes in patients with clinical (HR 1.24, 95% CI 0.90–1.72, p = 0.19) and technical features (HR 1.04, 95% CI 0.67–1.63, p = 0.85) of HIR.

Conclusion

In this multicenter real-world registry, administration of DAPT for more than 12 months in patients who have undergone PCI for bifurcation lesion is not associated with a reduced incidence of MACE in long-term follow-up.

Registration

ClinicalTrials.gov identifier no. NCT03450577.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B, ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720–826. https://doi.org/10.1093/eurheartj/ehad191.

    Article  CAS  PubMed  Google Scholar 

  2. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: the task force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur Heart J. 2020;41(3):407–77. https://doi.org/10.1093/eurheartj/ehz425.

    Article  PubMed  Google Scholar 

  3. Giustino G, Chieffo A, Palmerini T, et al. Efficacy and safety of dual antiplatelet therapy after complex PCI. J Am Coll Cardiol. 2016;68:1851–64.

    Article  CAS  PubMed  Google Scholar 

  4. Serruys PW, Takahashi K, Chichareon P, Kogame N, Tomaniak M, Modolo R, Chang CC, Komiyama H, Soliman O, Wykrzykowska JJ, de Winter RJ, Ferrario M, Dominici M, Buszman P, Bolognese L, Tumscitz C, Benit E, Stoll HP, Hamm C, Steg PG, Onuma Y, Jüni P, Windecker S, Vranckx P, Colombo A, Valgimigli M. Impact of long-term ticagrelor monotherapy following 1-month dual antiplatelet therapy in patients who underwent complex percutaneous coronary intervention: insights from the Global Leaders trial. Eur Heart J. 2019;40(31):2595–604. https://doi.org/10.1093/eurheartj/ehz453.

    Article  CAS  PubMed  Google Scholar 

  5. Shanmugam VB, Psaltis PJ, Tay L, et al. Procedural and clinical outcomes in management of bifurcationa lesions in ST elevation myocardial infarction. Heart Lung Circ. 2019. https://doi.org/10.1016/j.hlc.2019.01.011.

    Article  Google Scholar 

  6. Ninomiya K, Serruys PW, Garg S, et al. Predicted and observed mortality at 10 years in patients with bifurcation lesions in the SYNTAX trial. JACC Cardiovasc Interv. 2022;15:1231–42.

    Article  PubMed  Google Scholar 

  7. Grundeken MJ, Wykrzykowska JJ, Ishibashi Y, Garg S, de Vries T, Garcia- Garcia HM, Onuma Y, de Winter RJ, Buszman P, Linke A, Ischinger T, Klauss V, Eberli F, Corti R, Wijns W, Morice MC, di Mario C, Meier B, Jüni P, Yazdani A, Copt S, Windecker S, Serruys PW. First generation versus second generation drug- eluting stents for the treatment of bifurcations: 5-year follow-up of the LEADERS all-comers randomized trial. Catheter Cardiovasc Interv. 2016;87:E248–60.

    Article  PubMed  Google Scholar 

  8. Collet JP, Thiele H, Barbato E, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42:1289–367.

    Article  PubMed  Google Scholar 

  9. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Juni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40:87–165.

    Article  PubMed  Google Scholar 

  10. Baber U, Mehran R, Giustino G, Cohen DJ, Henry TD, Sartori S, Ariti C, Litherland C, Dangas G, Gibson CM, Krucoff MW, Moliterno DJ, Kirtane AJ, Stone GW, Colombo A, Chieffo A, Kini AS, Witzenbichler B, Weisz G, Steg PG, Pocock S. Coronary thrombosis and major bleeding after PCI with drug-eluting stents: risk scores from PARIS. J Am Coll Cardiol. 2016;67:2224–34.

    Article  PubMed  Google Scholar 

  11. Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237–69. https://doi.org/10.1093/eurheartj/ehy462.

    Article  PubMed  Google Scholar 

  12. Laskey WK, Yancy CW, Maisel WH. Thrombosis in coronary drug-eluting stents: report from the meeting of the Circulatory System Medical Devices Advisory Panel of the Food and Drug Administration Center for Devices and Radiologic Health, December 7–8, 2006. Circulation. 2007;115:2352–7. https://doi.org/10.1161/CIRCULATIONAHA.107.688416.

    Article  PubMed  Google Scholar 

  13. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011;123(23):2736–47. https://doi.org/10.1161/CIRCULATIONAHA.110.009449.

    Article  PubMed  Google Scholar 

  14. Mauri L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, Cutlip DE, Steg PG, Normand SL, Braunwald E, Wiviott SD, Cohen DJ, Holmes DR Jr, Krucoff MW, Hermiller J, Dauerman HL, Simon DI, Kandzari DE, Garratt KN, Lee DP, Pow TK, Ver Lee P, Rinaldi MJ, Massaro JM, DAPT Study Investigators. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med. 2014;371(23):2155–66. https://doi.org/10.1056/NEJMoa1409312.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Jensen EC, Magnani G, Bansilal S, Fish MP, Im K, Bengtsson O, Oude Ophuis T, Budaj A, Theroux P, Ruda M, Hamm C, Goto S, Spinar J, Nicolau JC, Kiss RG, Murphy SA, Wiviott SD, Held P, Braunwald E, Sabatine MS, PEGASUS-TIMI 54 Steering Committee and Investigators. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015;372(19):1791–800. https://doi.org/10.1056/NEJMoa1500857.

    Article  PubMed  Google Scholar 

  16. Rhee TM, Park KW, Kim CH, Kang J, Han JK, Yang HM, Kang HJ, Koo BK, Kim HS. dual antiplatelet therapy duration determines outcome after 2—but not 1-stent strategy in left main bifurcation percutaneous coronary intervention. JACC Cardiovasc Interv. 2018;11(24):2453–63. https://doi.org/10.1016/j.jcin.2018.09.020.

    Article  PubMed  Google Scholar 

  17. Zimarino M, Angiolillo DJ, Dangas G, Capodanno D, Barbato E, Hahn JY, Giustino G, Watanabe H, Costa F, Cuisset T, Rossini R, Sibbing D, Burzotta F, Louvard Y, Shehab A, Renda G, Kimura T, Gwon HC, Chen SL, Costa RA, Koo BK, Storey RF, Valgimigli M, Mehran R, Stankovic G. Antithrombotic therapy after percutaneous coronary intervention of bifurcation lesions. EuroIntervention. 2021;17(1):59–66. https://doi.org/10.4244/EIJ-D-20-00885.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Jang WJ, Ahn SG, Song YB, Choi SH, Chun WJ, Oh JH, Cho SW, Kim BS, Yoon JH, Koo BK, Yu CW, Jang YS, Tahk SJ, Kim HS, Gwon HC, Lee SY, Hahn JY. Benefit of prolonged dual antiplatelet therapy after implantation of drug-eluting stent for coronary bifurcation lesions: results from the Coronary Bifurcation Stenting Registry II. Circ Cardiovasc Interv. 2018;11(7): e005849. https://doi.org/10.1161/CIRCINTERVENTIONS.117.005849.

    Article  PubMed  Google Scholar 

  19. Cirillo P, Di Serafino L, Gamra H, Zimarino M, Barbato E, Briguori C, Amat-Santos IJ, Chieffo A, Erglis A, Gil RJ, Kedev SA, Petrov I, Radico F, Niglio T, Nakamura S, Costa RA, Kanic V, Perfetti M, Pellicano M, Maric K, Tesorio T, Vukcevic V, Esposito G, Stankovic G, EuroBifurcation Club. Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the EuroBifurcation Club registry. Panminerva Med. 2023;65(1):1–12. https://doi.org/10.23736/S0031-0808.22.04604-3.

    Article  PubMed  Google Scholar 

  20. Kogame N, Chichareon P, De Wilder K, Takahashi K, Modolo R, Chang CC, Tomaniak M, Komiyama H, Chieffo A, Colombo A, Garg S, Louvard Y, Jüni P, Steg PG, Hamm C, Vranckx P, Valgimigli M, Windecker S, Stoll HP, Onuma Y, Janssens L, Serruys PW. Clinical relevance of ticagrelor monotherapy following 1-month dual antiplatelet therapy after bifurcation percutaneous coronary intervention: Insight from GLOBAL LEADERS trial. Catheter Cardiovasc Interv. 2020;96:100–11.

    Article  PubMed  Google Scholar 

  21. Zimarino M, Briguori C, Amat-Santos IJ, Radico F, Barbato E, Chieffo A, Cirillo P, Costa RA, Erglis A, Gamra H, Gil RJ, Kanic V, Kedev SA, Maddestra N, Nakamura S, Pellicano M, Petrov I, Strozzi M, Tesorio T, Vukcevic V, De Caterina R, Stankovic G, EuroBifurcation Club. Mid-term outcomes after percutaneous interventions in coronary bifurcations. Int J Cardiol. 2019;283:78–83. https://doi.org/10.1016/j.ijcard.2018.11.139.

    Article  PubMed  Google Scholar 

  22. Yeh RW, Secemsky EA, Kereiakes DJ, Normand SL, Gershlick AH, Cohen DJ, Spertus JA, Steg PG, Cutlip DE, Rinaldi MJ, Camenzind E, Wijns W, Apruzzese PK, Song Y, Massaro JM, Mauri L, DAPT Study Investigators. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA. 2016;315:1735–49.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Wang HY, Wang Y, Yin D, Gao RL, Yang YJ, Xu B, Dou KF. Percutaneous coronary intervention complexity and risk of adverse events in relation to high bleeding risk among patients receiving drug-eluting stents: insights from a large single-center cohort study. J Interv Cardiol. 2020;25(2020):2985435. https://doi.org/10.1155/2020/2985435.

    Article  Google Scholar 

  24. Wang HY, Yin D, Zhao YY, Zhang R, Yang YJ, Xu B, Dou KF. Prognostic and practical validation of ESC/EACTS high ischemic risk definition on long-term thrombotic and bleeding events in contemporary PCI patients. J Atheroscler Thromb. 2022;29(4):502–26. https://doi.org/10.5551/jat.60129.

    Article  CAS  PubMed  Google Scholar 

  25. Yamamoto K, Watanabe H, Morimoto T, Obayashi Y, Natsuaki M, Domei T, Yamaji K, Suwa S, Isawa T, Watanabe H, Yoshida R, Sakamoto H, Akao M, Hata Y, Morishima I, Tokuyama H, Yagi M, Suzuki H, Wakabayashi K, Suematsu N, Inada T, Tamura T, Okayama H, Abe M, Kawai K, Nakao K, Ando K, Tanabe K, Ikari Y, Morino Y, Kadota K, Furukawa Y, Nakagawa Y, Kimura T, STOPDAPT-2 and STOPDAPT-2 ACS Investigators. Clopidogrel monotherapy after 1-month DAPT in patients with high bleeding risk or complex PCI. JACC Asia. 2023;3(1):31–46. https://doi.org/10.1016/j.jacasi.2022.09.011.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Apostolos A, Chlorogiannis D, Vasilagkos G, Katsanos K, Toutouzas K, Aminian A, Alexopoulos D, Davlouros P, Tsigkas G. Safety and efficacy of shortened dual antiplatelet therapy after complex percutaneous coronary intervention: a systematic review and meta-analysis. Hellenic J Cardiol. 2023;71:33–41. https://doi.org/10.1016/j.hjc.2023.01.005.

    Article  PubMed  Google Scholar 

  27. Genereux P, Giustino G, Redfors B, Palmerini T, Witzenbichler B, Weisz G, Stuckey TD, Maehara A, Mehran R, Kirtane AJ, Stone GW. Impact of percutaneous coronary intervention extent, complexity and platelet reactivity on outcomes after drug-eluting stent implantation. Int J Cardiol. 2018;268:61–7.

    Article  PubMed  Google Scholar 

  28. Ueki Y, Karagiannis A, Zanchin C, Zanchin T, Stortecky S, Koskinas KC, Siontis GCM, Praz F, Otsuka T, Hunziker L, Heg D, Moschovitis A, Seiler C, Billinger M, Pilgrim T, Valgimigli M, Windecker S, Raber L. Validation of high-risk features for stent-related ischemic events as endorsed by the 2017 DAPT guidelines. JACC Cardiovasc Interv. 2019;12:820–30.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Study data were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the Meshalkin National Medical Research Center, Russian Federation. REDCap is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources.

Author information

Authors and Affiliations

  1. Meshalkin National Medical Research Center, Ministry of Health of Russian Federation, 15 Rechkunovskaya st., Novosibirsk, 630055, Russian Federation

    Dmitrii Khelimskii, Aram Badoyan, Aleksey Baranov, Mahmudov Mamurjon, Serezha Manukian & Oleg Krestyaninov

  2. Tyumen Cardiology Research Center, Tomsk National Research Medical Center, Russian Academy of Sciences, Tomsk, 625026, Russian Federation

    Ivan Bessonov, Stanislav Sapozhnikov & Ruslan Utegenov

Authors
  1. Dmitrii Khelimskii
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ivan Bessonov
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stanislav Sapozhnikov
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aram Badoyan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Aleksey Baranov
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Mahmudov Mamurjon
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Serezha Manukian
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ruslan Utegenov
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Oleg Krestyaninov
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dmitrii Khelimskii.

Ethics declarations

Funding

No external funding was used in the preparation of this article.

Conflict of interest

Dmitrii Khelimskii, Ivan Bessonov, Stanislav Sapozhnikov, Aram Badoyan, Aleksey Baranov, Mahmudov Mamurjon, Sergey Manukyan, Ruslan Utegenov, and Oleg Krestyaninov declare that they have no potential conflicts of interest that might be relevant to the contents of this article.

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable.

Authors’ contributions

Dmitrii Khelimskii: conceptualization, analysis, investigation, methodology, project administration, supervision, validation, writing, reviewing, and editing. Ivan Bessonov: conceptualization, analysis, investigation, methodology, project administration, supervision, writing, reviewing, and editing. Stanislav Sapozhnikov: data curation, analysis, investigation, methodology, reviewing, and editing. Aram Badoyan: conceptualization, analysis, investigation, methodology, project administration, supervision, reviewing, and editing. Aleksey Baranov: data curation, analysis, investigation, methodology, and project administration. Mahmudov Mamurjon: data curation and investigation. Sergey Manukyan: data curation, analysis, investigation, project administration, validation, writing, reviewing, and editing. Ruslan Utegenov: data curation and investigation. Oleg Krestyaninov: conceptualization, project administration, supervision, reviewing, and editing.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Khelimskii, D., Bessonov, I., Sapozhnikov, S. et al. Impact of Prolonged Dual Antiplatelet Therapy After Bifurcation Percutaneous Coronary Intervention in Patients with High Ischemic Risk. Am J Cardiovasc Drugs (2024). https://doi.org/10.1007/s40256-024-00657-1

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s40256-024-00657-1

Search

Navigation