Geographical Variations in Patterns of DAPT Cessation and Two-Year PCI Outcomes: Insights from the PARIS Registry

Birgit Vogel; Jaya Chandrasekhar; Usman Baber; Ioannis Mastoris; Samantha Sartori; Melissa Aquino; Mitchell W. Krucoff; David J. Moliterno; Timothy D. Henry; Giora Weisz; C. Michael Gibson; Ioannis Iakovou; Annapoorna S. Kini; Serdar Farhan; Sabato Sorrentino; Michela Faggioni; Antonio Colombo; Philippe Gabriel Steg; Bernhard Witzenbichler; Alaide Chieffo; David J. Cohen; Thomas Stuckey; Cono Ariti; George D. Dangas; Stuart Pocock; Roxana Mehran

doi:10.1055/s-0039-1693463

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2019; 119(10): 1704-1711
DOI: 10.1055/s-0039-1693463

Atherosclerosis and Ischaemic Disease

Georg Thieme Verlag KG Stuttgart · New York

Geographical Variations in Patterns of DAPT Cessation and Two-Year PCI Outcomes: Insights from the PARIS Registry

Authors

Birgit Vogel

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Jaya Chandrasekhar

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Usman Baber

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Ioannis Mastoris

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Samantha Sartori

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Melissa Aquino

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Mitchell W. Krucoff

²Duke University School of Medicine, Durham, North Carolina, United States
David J. Moliterno

³University of Kentucky, Lexington, Kentucky, United States
Timothy D. Henry

⁴The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, United States
Giora Weisz

⁵Montefiore Medical Center, New York, New York, United States
C. Michael Gibson

⁶Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
Ioannis Iakovou

⁷Onassis Cardiac Surgery Centre, Athens, Greece
Annapoorna S. Kini

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Serdar Farhan

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Sabato Sorrentino

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Michela Faggioni

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Antonio Colombo

⁸San Raffaele Scientific Institute, Milan, Italy
Philippe Gabriel Steg

⁹Université Paris-Diderot, Sorbonne Paris-Cité, Paris, France
Bernhard Witzenbichler

¹⁰Helios Amper-Klinikum, Dachau, Germany
Alaide Chieffo

⁸San Raffaele Scientific Institute, Milan, Italy
David J. Cohen

¹¹St. Luke's Mid America Heart Institute, University of Missouri–Kansas City, Kansas City, Missouri, United States
Thomas Stuckey

¹²Moses Cone Heart and Vascular Center, LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina, United States
Cono Ariti

¹³London School of Hygiene and Tropical Medicine, London, United Kingdom
George D. Dangas

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
Stuart Pocock

¹³London School of Hygiene and Tropical Medicine, London, United Kingdom
Roxana Mehran

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

Abstract

Background Data on geographical variations in dual antiplatelet therapy (DAPT) cessation and the impact on outcomes after percutaneous coronary intervention (PCI) are limited. We sought to evaluate geographical patterns of DAPT cessation and associated outcomes in patients undergoing PCI in the United States versus Europe.

Methods Analyzing data from the PARIS registry, we studied 3,660 U.S. patients (72.9%) and 1,358 European patients (27.1%) that underwent PCI with stent implantation. DAPT cessation was classified as physician-recommended discontinuation, interruption (< 14 days), or disruption due to bleeding or noncompliance. The primary endpoint was 2-year major adverse cardiovascular events (MACE) defined as a composite of cardiac death, stent thrombosis, myocardial infarction, or target lesion revascularization.

Results Cardiovascular risk factors were more common in the United States, whereas procedural complexity was greater in Europe. The incidence of 2-year DAPT discontinuation was significantly lower in U.S. versus European patients (30.7% vs. 65.6%; p < 0.001); however, rates of interruption (13.7% vs. 1.5%, p < 0.001) and disruption (17.7% vs. 5.1%, p < 0.001) were higher. DAPT discontinuation was associated with lower adjusted risk, whereas DAPT disruption was associated with greater risk for 2-year MACE, without interaction by region. After adjustment for baseline characteristics and DAPT cessation, 2-year MACE risk was not statistically different between regions (10.3% for Europe vs. 11.9% for U.S., adjusted hazard ratio 0.81, 95% confidence interval 0.65–1.01, p = 0.065).

Conclusion DAPT cessation patterns, along with clinical and angiographic risk, vary substantially between PCI patients in the U.S. versus Europe. Despite such differences, cardiovascular risk associated with DAPT cessation remains uniform.

Keywords

dual antiplatelet therapy - percutaneous coronary intervention - dual antiplatelet therapy cessation - geographical differences - adherence

Full Text

References

References
1 Neumann FJ, Sousa-Uva M, Ahlsson A. , et al; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2019; 40 (02) 87-165
2 Levine GN, Bates ER, Bittl JA. , et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68 (10) 1082-1115
3 Iakovou I, Schmidt T, Bonizzoni E. , et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293 (17) 2126-2130
4 Mehran R, Baber U, Steg PG. , et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet 2013; 382 (9906): 1714-1722
5 Cutlip DE, Windecker S, Mehran R. , et al; Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115 (17) 2344-2351
6 Thygesen K, Alpert JS, White HD. ; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J 2007; 28 (20) 2525-2538
7 Mehran R, Rao SV, Bhatt DL. , et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 2011; 123 (23) 2736-2747
8 Chandrasekhar J, Baber U, Sartori S. , et al. Patterns and associations between DAPT cessation and 2-year clinical outcomes in left main/proximal LAD versus other PCI: results from the Patterns of Non-Adherence to Dual Antiplatelet Therapy in Stented Patients (PARIS) registry. Int J Cardiol 2017; 243: 132-139
9 Dangas GD, Claessen BE, Mehran R. , et al. Development and validation of a stent thrombosis risk score in patients with acute coronary syndromes. JACC Cardiovasc Interv 2012; 5 (11) 1097-1105
10 Baber U, Mehran R, Giustino G. , et al. Coronary thrombosis and major bleeding after PCI with drug-eluting stents: risk scores from PARIS. J Am Coll Cardiol 2016; 67 (19) 2224-2234
11 Yeh RW, Secemsky EA, Kereiakes DJ. , et al; 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 (16) 1735-1749
12 Silber S, Albertsson P, Avilés FF. , et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. Eur Heart J 2005; 26 (08) 804-847
13 King III SB, Smith Jr SC, Hirshfeld Jr JW. , et al; ACC/AHA/SCAI. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008; 51 (02) 172-209
14 Bueno H, Pocock S, Danchin N. , et al. International patterns of dual antiplatelet therapy duration after acute coronary syndromes. Heart 2017; 103 (02) 132-138
15 Cutler DM, Everett W. Thinking outside the pillbox--medication adherence as a priority for health care reform. N Engl J Med 2010; 362 (17) 1553-1555
16 Moalem K, Baber U, Chandrasekhar J. , et al. Incidence, predictors, and outcomes of DAPT disruption due to non-compliance vs. bleeding after PCI: insights from the PARIS Registry. Clin Res Cardiol 2019; 108 (06) 643-650
17 Czarny MJ, Nathan AS, Yeh RW, Mauri L. Adherence to dual antiplatelet therapy after coronary stenting: a systematic review. Clin Cardiol 2014; 37 (08) 505-513
18 Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery--a prospective outcome study. Br J Anaesth 2006; 96 (06) 686-693
19 Gandhi NK, Abdel-Karim AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv 2011; 77 (07) 972-976