JIM Today 2018 - Saturday - page 7

Issue 3 
Saturday
 24 February 2018 
JIM today
7
jects with atrial fibrillation undergoing
percutaneous coronary intervention.
It demonstrated reduced bleeding
risk with 15 mg rivaroxaban + P2Y
12
inhibitor alone for one year, or 2.5
mg twice daily rivaroxaban + DAPT
(for 1, 6, or 12 months), as compared
to vitamin K antagonist + DAPT (for
1, 6, or 12 months). Rates of stroke,
MI, or CV death were not statistically
significant between groups.
4
Dr Mikhail also noted the REDU-
AL PCI trial (randomised evaluation
of dual antithrombotic therapy
with dabigatran versus triple
therapy with warfarin in patients
with nonvalvular atrial fibrillation
undergoing percutaneous coronary
intervention), wherein patients
were randomised to either warfarin
+ aspirin + clopidogrel/ticagrelor,
or dabigatran (110 mg or 150 mg
twice daily) + P2Y
12
inhibitor. Bleeding
risk was significantly lower at mean
follow-up of 14 months in the dabi-
gatran + P2Y
12
inhibitor group, with
no difference found in rate of stroke,
systemic embolism, MI, unplanned
revascularisation, or death.
5
Choice of stent can also affect
DAPT duration, explained Dr Mikhail.
“More studies are needed, but as an
example, the Biofreedom [Biosensors
International, Singapore] and zotaroli-
mus-eluting Endeavor [Medtronic,
USA] stents, can be used with shorter
duration of DAPT.”
ZEUS (Zotarolimus-eluting
Endeavor sprint stent in uncertain
DES candidates) and LEADERS FREE
(prospective randomised compari-
son of the BioFreedom Biolimus A9
drug-coated stent versus the Gazelle
bare-metal stent in patients at high
bleeding risk), assessed the use of
one month of DAPT in patients at
high risk of bleeding. These studies
found that patients implanted with
drug-coated stent fared better at
one year in terms of MI, target vessel
revascularisation, or death (in ZEUS),
and in terms of MI, stent thrombosis,
and death (in LEADERS FREE), relative
to bare metal stenting.
6,7
Concluding with a reflection on
current ESC guidelines for patients
on OACs undergoing PCI, Dr Mikhail
stated: “We don’t know the exact
answer and more studies are needed.
But the length of triple therapy
should be kept as short
as possible because of
the risk of bleeding. We
should be considering
the use of DOACs rather
than warfarin, clopidogrel
rather than prasugrel or
ticagrelor. We should also
consider a lower dose of
DOAC as well as the use
of dedicated new-gen-
eration stents to lower the duration
of DAPT.
“In patients with a high risk of
ischaemia and low bleeding risk, we
should be using triple therapy for up
to six months followed by OAC and a
single antiplatelet agent. For patients
with a high bleeding risk, we should
be using one month of triple therapy
followed by dual therapy. After 12
months we should then consider us-
ing OAC alone.”
References
1. Vidula MK et al. Duration of Dual Antiplatelet
Therapy for Stented Patients: An Update for
the Clinician. Prog Cardiovasc Dis. 2018 [Article
in Press].
2. Secemsky EA, Yeh RW, Kereiakes DJ, et al.
Mortality following cardiovascular and bleeding
events occurring beyond 1 year after coronary
stenting a secondary analysis of the dual anti-
platelet therapy (DAPT) study. JAMA Cardiol.
2017;2(5):478-487.
3. DewildeWJ, Oirbans T, Verheugt FW, et al.
Use of clopidogrel with or without aspirin in
patients taking oral anticoagulant therapy and
undergoing percutaneous coronary interven-
tion: an open-label, randomised, controlled
trial. Lancet. 2013;381(9872):1107-1115.
4. Gibson CM, Mehran R, Bode C, et al.
Prevention of bleeding in patients with atrial
fibrillation undergoing PCI. N Engl J Med.
2016;375(25):2423-2434.
5. Cannon CP, Bhatt DL, Oldgren J, et al. Dual
antithrombotic therapy with dabigatran
after PCI in atrial fibrillation. N Engl JMed.
2017;377(16):1513-1524.
6. Valgimigli M, Patialiakas A, Thury A, et al.
Zotarolimus-eluting versus bare-metal stents in
uncertain drug-eluting stent candidates. J Am
Coll Cardiol. 2015;65(8):805-815.
7. Urban P, Meredith IT, Abizaid A, et al.
Polymer-free drug-coated coronary stents in
patients at high bleeding risk. N Engl J Med.
2015;373(21):2038-2047.
“The length of triple therapy
should be kept as short as
possible because of the risk of
bleeding.”
Ghada Mikhail
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