How to Select the Right Patient for Long-Term DAPT

Issue of Debate at C3, June 17-20, 2018

Interventional Academy Speaks with Prof David Erlinge, MD, PhD, FESC, FACC, Head, Department of Cardiology, Lund, Sweden

Treatment with dual antiplatelet therapy (DAPT) is a cornerstone to protect against myocardial infarction (MI) and stroke, but the duration of the treatment is constantly debated. Some studies have even found trends towards increased mortality and cancer relating to duration of DAPT treatment.

Upon request from the Food and Drug Administration, Dr. Elmariah, Director, Interventional Structural Heart Disease, VA Boston Healthcare System, and his co-workers performed a patient level meta-analysis.  They did so on nearly 100,000 patient years by combining the studies CURE, CHARISMA, ACTIVE-A, CREDO, SPS3 and DAPT studies. The results of this meta-analysis demonstrated no effect of clopidogrel on mortality or cancer, which is reassuring. There was also a clear reduction in MI, but it came with a cost of increased rates of bleeding. The authors conclude that DAPT should only be continued when there is a clear risk of ischemic event and low bleeding risk. However, finding these patients is not easy.

Over time, and in reviewing these various studies, different scores have been developed but usually the risk of bleeding follows the risk of MI. Furthermore, the PEGASUS trial demonstrated that a more potent P2Y12 –inhibition beyond one year with ticagrelor 60 mg reduces the risk of MI, but again, with the cost of increased bleeding events. There are definitely patients in which new ischemic events would be devastating and should be offered long-term DAPT.

This issue continues to garner continued research and deliberation and we look forward to further discussing and debating “How to select the right patients for long-term DAPT” at the upcoming C3 meeting this June in Orlando, Florida.

 

Elmariah, S et al., Circ Cardiovasc Interv. 2018

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