Author + information
- Sorin Brener1,
- Ajay Jayant Kirtane2,
- Michael Rinaldi3,
- Bernhard Witzenbichler4,
- Franz-Josef Neumann5,
- Timothy Henry6,
- David Cox7,
- Peter L. Duffy8,
- Ernest Mazzaferri Jr.9,
- Bruce Brodie10,
- Roxana Mehran11,
- Thomas McAndrew12 and
- Gregg Stone13
- 1New York Methodist Hospital, Brooklyn, New York, United States
- 2Columbia University / New York-Presbyterian Hospital, New York, New Jersey, United States
- 3Sanger Heart and Vascular Institute/Carolinas Medical Center, Charlotte, North Carolina, United States
- 4Helios Amper-Klinikum, Dachau, Germany
- 5Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
- 6Cedars-Sinai Medical Center, Los Angeles, California, United States
- 7Lehigh Valley Health Network, Bethlehem, Pennsylvania, United States
- 8FirstHealth Cardiology Services, Pinehurst, North Carolina, United States
- 9Ohio State University Medical Center, Columbus, Ohio, United States
- 10LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, North Carolina, United States
- 11Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, United States
- 12Cardiovascular Research Foundation, New York, New York, United States
- 13Cardiovascular Research Foundation, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains in dispute, particularly after 12 months. The DAPT Score was developed from the DAPT trial to identify pts who may benefit the most from extended therapy. We sought to assess the performance of the DAPT risk score in the all-comers Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents (ADAPT-DES) registry, and to test the utility of additional predictors of events on its performance.
Patients free from ischemic or hemorrhagic events after 1 year of DAPT after successful DES implantation were analyzed. The DAPT score was calculated for each pt and outcomes between 1 and 2 years were examined according to the DAPT trial median score (≥2 vs. <2). ROC curves for the DAPT score were built for ischemic events (myocardial infarction [MI] or stent thrombosis [ST]) and clinically relevant bleeding. High-platelet reactivity (HPR) was then added to the ischemic model, and HPR, chronic oral anticoagulation therapy, history of anemia, and baseline hemoglobin were added to bleeding model. Interaction between pts remaining on DAPT and risk score quartile was tested for ischemic and bleeding events, after adjustment for propensity after the first year post-PCI.
Among 8,582 pts in ADAPT-DES, 5,397 were event-free after 1 year, 3617 (67.0%) of whom remained on DAPT. Between 1 and 2 years, ischemic and hemorrhagic events occurred in 413 and 124 pts, respectively. Pts with higher vs. lower DAPT scores (≥2 vs. <2) had higher 1-2 year rates of ischemic events (5.6% vs 3.0%, p<0.0001), but similar rates of bleeding (2.2% vs 2.4%, p=0.73). The DAPT score had moderate discrimination for MI or ST between 1 and 2 years (c-statistic=0.615, compared with 0.68 in DAPT trial) and adequate calibration (PHL=0.41). The addition of HPR did not significantly improve discrimination for ischemic events (c-statistic=0.628, p=0.27). The DAPT score was ineffective in predicting bleeding between 1 and 2 years (c-statistic=0.508) but had adequate calibration (PHL=0.11). The addition of HPR and other bleeding correlates significantly improved the discrimination for bleeding (c-statistic=0.606, p<0.0001). The results were similar in pts maintained on DAPT vs aspirin only beyond 1 year after PCI.
In the in the ADAPT-DES registry, the DAPT score was reasonably predictive for ischemic events between 1 and 2 years after PCI, but was not useful to predict bleeding events. Prediction of bleeding can be significantly improved by addition of variables not incorporated in the DAPT score.