dual anti platelet in cbifarcation

1. Benefit of Prolonged Dual Antiplatelet
Therapy After Implantation of Drug-Eluting
Stent for Coronary Bifurcation Lesions
Dr Sami Nazrul Islam
MD Cardiology ( Final Part Student)
NATIONAL HEART FOUNDATION HOSPITAL AND RESEARCH INSTITUTE
Circulation Cardiovascular Interventions. Published July 13, 2018 vol 11

2. • Dual antiplatelet therapy (DAPT) of aspirin and P2Y12 inhibitor is a
cornerstone therapy afterimplantation of drug-eluting stents (DESs).
• Although several randomized trials and meta-analysis have compared the
efficacy and safety of shortduration and extended DAPT, the optimal
duration of DAPT remains controversial. Especially, data are limited on
the optimal or minimal necessary duration of DAPT after DES
implantation for coronary bifurcation lesions.

3. • Although recent studies reported that short-duration DAPT of 3 or 6
months is associated with increased risk of 1-year adverse events in
patients undergoing percutaneous coronary intervention (PCI) for complex
lesions and late stent thrombosis after crush technique is prevented by
prolonged DAPT, whether DAPT >12 months is beneficial after PCI for
bifurcation lesions is uncertain.
• Because of variable risk of stent thrombosis according to lesion
characteristics, studies about optimal duration of DAPT or strategy of
antiplatelet therapy– reducing ischemic events and minimizing fatal
bleeding in patient undergoing PCI for bifurcation lesion is important.

4. • Therefore, they investigated the effects of DAPT duration on
long-term clinical outcomes in patients receiving DES for
bifurcation lesions, including left main lesions using data from the
Coronary Bifurcation Stenting Registry II.

5. Study Population
• The Coronary Bifurcation Stenting Registry II is a retrospective
multicenter registry of patients with coronary bifurcation lesions who
underwent PCI with a DES.
• From January 2003 to December 2009, a total of 2897 consecutive
patients from 18 major coronary intervention centers in Korea were
enrolled.

6. Inclusion criteria
(1) Coronary bifurcation lesion treated solely with a DES
(2) Main vessel diameter ≥2.5 mm and side branch (SB) diameter ≥2.3.

7. Exclusion Criteria
(1) Cardiogenic shock or experience of cardiopulmonary resuscitation.
(2) Protected left main disease.

8. • 2082 patients who met the selection criteria were divided into 2 groups
based on duration of DAPT
• (aspirin+clopidogrel) use: DAPT ≥12-month group and DAPT <12-month
group .
• Analysis was performed to classify patients into treatment groups based
on 12-month antiplatelet treatment after PCI and to evaluate prognosis.

9. PCI and Pharmacologic Therapy
• PCI was performed according to the practice guidelines established by the Korean
Society of Interventional Cardiology.
• All patients received loading doses of aspirin (300 mg) and clopidogrel (300–600
mg) before PCI unless they had previously received these antiplatelet
medications.
• Anticoagulation during PCI was performed.
• Using low molecular weight heparin or unfractionated heparin to achieve an
activated clotting time of 250 to 300 seconds.

10. • The access site, type of used DES, stent technique, use of
intravascular ultrasound, and glycoprotein IIb/IIIa receptor inhibitor
treatment were all at the operator’s discretion.
• After the procedure, all patients were recommended to receive
optimal pharmacological therapy of statin, β-blocker, or angiotensin-
converting enzyme inhibitor/angiotensin receptor blocker at the
discretion of the responsible clinicians.

11. • Clinical, angiographic, procedural, and outcome data were collected.
• Status of antiplatelet therapy, date and duration of prescribed antiplatelet
agents were obtained.
• Additional information was obtained by reviewing medical records or by
telephone contact, if necessary.
• Bifurcation lesions were classified according to the Medina classification.

12. Study Outcomes and Definitions
• Primary outcome was
• a composite of all-cause death or MI at 4 years after the index procedure.
• Secondary outcomes
• were all-cause death, cardiac death, MI, stent thrombosis, and cerebrovascular
accident.
• All deaths were considered to be of cardiac origin unless a definite noncardiac cause
could be established.

14. RESULTS
Baseline Characteristics and Antiplatelet Therapy
• Of 2082 patients who were event free at 12 months after index procedure,
1776 patients received DAPT >12 months (DAPT ≥12-month group)
• 306 patients did not (DAPT <12-month group).
• Baseline clinical characteristics between 2 groups were not significantly
different except dyslipidemia

17. Clinical Outcomes
• All-cause death tended to occur less frequently in the DAPT ≥12-
month group than in the DAPT <12-month group
• At 4 years after PCI, 37 all-cause deaths or MI occurred in the DAPT
≥12-month group and 26 in the DAPT <12-month group.

18. • The incidence of cardiac death (0.5% versus 2.2%)
• MI (0.5% versus 9.7%)
• Stent thrombosis was lower in the DAPT ≥12-month group than the
DAPT <12-month group.

20. DISCUSSION
• The main finding was that prolonged DAPT >12 months after the
index procedure was associated with reduced risk of all-cause death
or MI compared with DAPT <12 months.

21. • Bifurcation lesions are not uncommon and are reported to account
for >30% of all coronary lesions.
• Current guidelines recommend DAPT for 6 months after implantation
of DES in patients with stable ischemic heart disease and for at least
12 months for patients with acute coronary syndrome.

22. • Many patients were actually taking DAPT ≥12 months and, as many
interventional cardiologists expect, MI or stent thrombosis occurred less
frequently in the DAPT ≥12-month group than in the DAPT <12-month group
among patients who were event free at 12 months after index procedure.
• There are several plausible explanations for our results. First, the risk of
major adverse cardiac events was reported to be higher in bifurcation
lesions compared with nonbifurcation lesions. Excessive metal scaffolding,
malapposed stent struts, inadequate stent expansion, and excessive metal
protruding into vessel lumen may result in delayed reendothelialization.

23. • The study demonstrated that prolonged DAPT ≥12 months was associated
with improved long-term outcomes over 4 years for all bifurcation lesions
including those treated with 1-stent technique .
• They included only bifurcation lesions with SB ≥2.3 mm and left main
bifurcation lesions. Therefore, if stent thrombosis occurred, it might result
in death or clinically evident MI. Prolonged DAPT might reduce stent
thrombosis and, in turn, prevent death orMI.

24. • Many patients in the study received first-generationDESs. Although
first-generation DESs are no longer implanted, patients who have
received the first-generation DES are still followed-up in daily
practice. Moreover, second-generation DESs are associated with
lower rates of death, definite stent thrombosis, and MI than first-
generation DESs.

25. • The strength of the study is a large sample size with minimal exclusion
criteria and a relatively long-term follow-up duration.
• Inclusion of left main lesions was a unique advantage of the study.

26. Limitations.
• Its design was nonrandomized, which might have affected the results
• Data on bleeding events were unavailable. Prolonged DAPT ≥12 months might
increase the risk of major bleeding which could offset benefits from reducing
ischemic events.
• No data on necessity for anticoagulation nor information on medical treatment
except DAPT.
• All events might not be have been collected because this was a retrospective study.

27. WHAT IS KNOWN
• Dual antiplatelet therapy (DAPT) of aspirin and P2Y12 inhibitor is a
cornerstone therapy after implantation of drug-eluting stents.
• Short-duration DAPT of 3 or 6 months is associated with increased risk of 1-
year adverse events in patients undergoing
percutaneous coronary intervention for complex lesions, and late stent
thrombosis after percutaneous coronary intervention is prevented by
prolonged DAPT.

28. WHAT THE STUDY ADDS
• The new finding of the present study is that prolonged DAPT >12 months after
percutaneous coronary intervention for coronary bifurcation lesion is associated with
reduced risk of all-cause death or MI compared with DAPT <12 months.
• The treatment effect of prolonged DAPT was consistent across various subgroups
regardless of lesion location, stenting technique, or type of used drug-eluting stent in
patients undergoing percutaneous coronary intervention for bifurcation lesion.

29. Thank You

30. Thank You

31. • Bifurcation lesions were classified
• according to the Medina classification, in which proximal
• main vessel, distal main vessel, and SB components of the
• bifurcation were each assigned a score of 1 or 0 for presence
• or absence of >50% stenosis classification.14 Medina classification
• type (1.1.1), (1.0.1), and (0.1.1) lesions were defined
• as true bifurcation lesions.