Adopting a clopidogrel-based DAPT strategy after PCI boosts outcomes for heart attack patients
![Large peridevice leaks after left atrial appendage occlusion (LAAO) are incredibly rare and not associated with a greater risk of adverse outcomes, according to new research published in JACC: Clinical Electrophysiology.[1] Smaller residual links are more common, however, and associated with a risk of thromboembolic and bleeding events.](/sites/default/files/styles/top_stories/public/2018-08/olderpatient-doctor.jpg.webp?itok=Cv18wcDr)
Among stabilized MI patients who have already undergone percutaneous coronary intervention (PCI), a uniform unguided de-escalation dual antiplatelet therapy (DAPT) strategy that involves switching ticagrelor to clopidogrel was associated with improved outcomes, according to data published in The Lancet.
The study's authors focused on 2,901 patients with acute MI who were screened after undergoing successful PCI from Feb. 2014 to Dec. 2018. All data came from the TALOS-AMI trial in South Korea. Sixteen percent of patients were women, and the mean patient age was 60 years old. In addition, 27.1% of patients had diabetes, 48.9% had hypertension, and 53.9% presented with STEMI.
The primary endpoint of the study was a composite of cardiovascular death, MI, stroke or bleeding types 2, 3 or 5, as defined by Bleeding Academic Research Consortium (BARC) criteria, from one to 12 months following PCI.
After exclusions were made, the team landed on a total of 2,697 patients. Each patient was randomly assigned to the de-escalation group (receiving clopidogrel plus aspirin) or the active control group (receiving ticagrelor plus aspirin) one month after a successful PCI procedure.
Of the 1,349 patients who belonged to the de-escalation group, 1,208 were given the allocated treatment during the study period, 31 stopped taking antiplatelet medication, 62 received ticagrelor plus aspirin, and 48 used other antiplatelet regimens.
Of the 1,348 patients assigned to the active control group, 1,172 received the allocated treatment: 30 stopped taking antiplatelet medication, 24 were given clopidogrel plus aspirin and 22 followed different antiplatelet routines.
Overall, after 12 months, the primary endpoint occurred in 4.6% of patients in the de-escalation group and 8.2% of patients in the active control group. There was no substantial difference noticed in the composite of CV death, MI, and stroke between the two groups.
Meanwhile, a composite of BARC bleeding types 2, 3, or 5 did not occur as often in the deescalation group (3%) as they did in the active control group (5.6%).
“The uniform, unguided de-escalation DAPT strategy was associated with a 45% lower risk of net clinical benefits for the next 11 months than the ticagrelor-based DAPT strategy," wrote lead author Chan Joon Kim, MD, a specialist at St. Mary’s Hospital in South Korea, and colleagues. "The absolute risk reduction was 3.6%, which was mainly attributed to a significant decrease in bleeding risk.”
Kim et al. pointed out that the findings from the study should be restricted to uncomplicated, stabilized patients with acute MI undergoing PCI.
“In patients with acute myocardial infarction with complex lesions, major adverse events in the acute phase, ticagrelor intolerance, or only medical treatment, this kind of de-escalation strategy cannot be extrapolated,” the authors wrote.
Read the full study here.