Incidence, Patterns, and Associations Between Dual-Antiplatelet Therapy Cessation and Risk for Adverse Events Among Patients With and Without Diabetes Mellitus Receiving Drug-Eluting Stents: Results From the PARIS Registry.

OBJECTIVES: The aim of this study was to examine the frequency and clinical impact of different cessation patterns of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention with drug-eluting stents among patients with and those without diabetes mellitus (DM). BACKGROUND: Early DAPT suspension after percutaneous coronary intervention increases the risk for major adverse cardiac events. However, temporal variability in risk and relation to DAPT cessation patterns among patients with DM remain unclear. METHODS: Using data from the PARIS (Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients) registry, 1,430 patients with DM (34%) and 2,777 without DM (66%) treated with drug-eluting stents were identified. DAPT cessation modes were classified as temporary interruption (<14 days), disruption because of bleeding or poor compliance, and physician-recommended discontinuation. RESULTS: During 2-year follow-up, DM was associated with an increased risk for thrombotic events but a similar risk for bleeding. The cumulative incidence of DAPT cessation was significantly lower in patients with versus those without DM (50.1% vs. 55.4%; p < 0.01), driven largely by less frequent physician-guided discontinuation beyond 1 year. In contrast, 2-year rates of interruption and disruption were similar between groups. When DAPT was interrupted or discontinued under physician guidance, the risk for major adverse cardiac events was unchanged compared with patients with DM on uninterrupted DAPT. Conversely, when DAPT was disrupted, the risk for major adverse cardiac events increased compared with uninterrupted DAPT, regardless of diabetic status, with no evidence of statistical interaction. CONCLUSIONS: DAPT cessation patterns vary according to diabetic status, with less frequent physician-guided discontinuation among patients with DM. The presence of DM does not emerge as a modifier of cardiovascular risk after DAPT cessation

Associations Between Complex PCI and Prasugrel or Clopidogrel Use in Patients With Acute Coronary Syndrome Who Undergo PCI: From the PROMETHEUS Study.

BACKGROUND: Potent P2Y12 inhibitors might offer enhanced benefit against thrombotic events in complex percutaneous coronary intervention (PCI). We examined prasugrel use and outcomes according to PCI complexity, as well as analyzing treatment effects according to thienopyridine type. METHODS: PROMETHEUS was a multicentre observational study that compared clopidogrel vs prasugrel in acute coronary syndrome patients who underwent PCI (n = 19,914). Complex PCI was defined as PCI of the left main, bifurcation lesion, moderate-severely calcified lesion, or total stent length ≥ 30 mm. Major adverse cardiac events (MACE) were a composite of death, myocardial infarction, stroke, or unplanned revascularization. Outcomes were adjusted using multivariable Cox regression for effect of PCI complexity and propensity-stratified analysis for effect of thienopyridine type. RESULTS: The study cohort included 48.9% (n = 9735) complex and 51.1% (n = 10,179) noncomplex patients. Second generation drug-eluting stents were used in 70.1% complex and 66.2% noncomplex PCI patients (P < 0.0001). Complex PCI was associated with greater adjusted risk of 1-year MACE (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.20-1.39; P < 0.001). Prasugrel was prescribed in 20.7% of complex and 20.1% of noncomplex PCI patients (P = 0.30). Compared with clopidogrel, prasugrel significantly decreased adjusted risk for 1-year MACE in complex PCI (HR, 0.79; 95% CI, 0.68-0.92) but not noncomplex PCI (HR, 0.91; 95% CI, 0.77-1.08), albeit there was no evidence of interaction (P interaction = 0.281). CONCLUSIONS: Despite the use of contemporary techniques, acute coronary syndrome patients who undergo complex PCI had significantly higher rates of 1-year MACE. Adjusted magnitude of treatment effects with prasugrel vs clopidogrel were consistent in complex and noncomplex PCI without evidence of interaction

Postprocedure chest pain after coronary stenting: implications on clinical restenosis

AbstractObjectivesThe goal of this study was to analyze the incidence and predictors of postprocedure chest pain (PPCP) after percutaneous coronary intervention (PCI) and its correlation with clinical restenosis.BackgroundChest pain after PCI occurs frequently even in the absence of procedural events and is considered to be due to vasospasm or coronary artery stretch. The short- and long-term significance of PPCP after otherwise successful stenting is not clear.MethodsWe analyzed 1,362 patients undergoing coronary stenting for PPCP, procedural and in-hospital events, 30-day major adverse cardiac events, and target vessel revascularization (TVR) at 6 to 9 months.ResultsThere were 488 patients with PPCP and, of these, 312 patients were excluded due to procedural events. The remaining 176 patients with PPCP were compared with 874 patients without PPCP. Creatine kinase-MB isoenzyme elevation occurred in 25.6% of the PPCP group versus 9.6% of the no PPCP group (p < 0.001). Despite similar reference vessel diameter, the PPCP group had larger postprocedure minimum lumen diameter, higher stent-to-vessel ratio, and higher inflation pressure versus the no PPCP group (p < 0.01). At 30 days, the emergency room visits and repeat catheterization (16% vs. 2.7%; p < 0.001) were higher in the PPCP group versus the no PPCP group, but repeat intervention was similar. At 6- to 9-month follow-up, the TVR was significantly higher in the PPCP group compared with the no PPCP group (29.5% vs. 16.6%; p < 0.01).ConclusionsOur analysis suggests micromyonecrosis and vessel stretch as causes of PPCP. Postprocedure chest pain is associated with similar short-term outcome as no PPCP, but has higher restenosis, perhaps mediated by deep vessel wall injury. Therefore, PPCP may identify patients at high risk for restenosis