Antiplatelet Therapy Discontinuation and the Risk of Serious Cardiovascular Events after Coronary Stenting: Observations from the CREDO-Kyoto Registry Cohort-2

<div><p>Relation of antiplatelet therapy (APT) discontinuation with the risk of serious cardiovascular events has not been fully addressed yet. This study is aimed to evaluate the risk of ischemic event after APT discontinuation based on long-term APT status of large cohort. In the CREDO-Kyoto Registry Cohort-2 enrolling 15939 consecutive patients undergoing first coronary revascularization, 10470 patients underwent percutaneous coronary intervention either with bare-metal stents (BMS) only (N=5392) or sirolimus-eluting stents (SES) only (N=5078). Proportions of patients taking dual-APT were 67.3% versus 33.4% at 1-year, and 48.7% versus 24.3% at 5-year in the SES and BMS strata, respectively. We evaluated daily APT status (dual-, single- and no-APT) and linked the adverse events to the APT status just 1-day before the events. No-APT as compared with dual- or single-APT was associated with significantly higher risk for stent thrombosis (ST) beyond 1-month after SES implantation (cumulative incidence rates beyond 1-month: 1.23 versus 0.15/0.29, P<0.001/P<0.001), while higher risk of no-APT for ST was evident only until 6-month after BMS implantation (incidence rates between 1- and 6-month: 8.43 versus 0.71/1.20, P<0.001/P<0.001, and cumulative incidence rates beyond 6-month: 0.31 versus 0.11/0.08, P=0.16/P=0.08). No-APT as compared with dual- or single-APT was also associated with significantly higher risk for spontaneous myocardial infarction (MI) and stroke regardless of the types of stents implanted. Single-APT as compared with dual-APT was not associated with higher risk for serious adverse events, except for the marginally higher risk for ST in the SES stratum. In conclusion, discontinuation of both aspirin and thienopyridines was associated with increased risk for serious cardiovascular events including ST, spontaneous MI and stroke beyond 1-month after coronary stenting.</p></div

Incidence Rates for Stroke in the SES group.

<p>(A) Incidence rates of stroke in the SES group in the pre-specified time intervals, and (B) cumulative incidence rates of stroke in the SES group. APT = antiplatelet therapy, DAPT = dual-APT, SAPT = single-APT, SES = sirolimus-eluting stents, and ST = stent thrombosis.</p

Prevalence of Each APT Status during Follow-Up.

<p>Prevalence of each APT status during follow-up in the SES group (A), and in the BMS group (B). APT = antiplatelet therapy, BMS = bare-metal stents, DAPT = dual-APT, PCI = percutaneous coronary intervention, and SES = sirolimus-eluting stents.</p

Duration from Drug Discontinuation to the Onset of Adverse Events.

<p>Duration of SAPT is the number of days from the last day when patients received DAPT to the day of adverse event, without any consideration for days with no-APT in between, if any, for the patients who had adverse event on SAPT. Duration of no-APT is the number of consecutive days with no-APT just before the adverse event.</p><p>APT = antiplatelet therapy, BMS = bare-metal stents, DAPT = dual-APT, IQR = interquartile range, MI = myocardial infarction, SAPT = single-APT, SES = sirolimus-eluting stents, and ST = stent thrombosis.</p><p>Duration from Drug Discontinuation to the Onset of Adverse Events.</p

Unadjusted and Adjusted Risk of No-APT and SAPT Relative to DAPT for Serious Adverse Events beyond 1-month after index PCI.

<p>APT = no antiplatelet therapy, BMS = bare-metal stents, CI = confidence interval, DAPT = dual-APT, OR = odds ratio, SAPT = single-APT, and SES = sirolimus-eluting stents.</p><p>Unadjusted and Adjusted Risk of No-APT and SAPT Relative to DAPT for Serious Adverse Events beyond 1-month after index PCI.</p

Baseline characteristics, medications, angiographic and procedural characteristics during the index hospitalization in the propensity score-matched cohort.

(DOCX)</p

Fig 2 -

Crude kaplan-meier curves for the cumulative incidence of (A) all-cause death/MI/stroke, (B) all-cause death, (C) any coronary revascularization, and (D) all-cause death/MI/stroke/any coronary revascularization. PCI = percutaneous coronary intervention; CABG = coronary artery bypass grafting; MI = myocardial infarction.</p

Subgroup analyses for the primary outcome measure (death/MI/stroke).

Subgroup analyses for the primary outcome measure (death/MI/stroke).</p

Baseline characteristics and medications during the index hospitalization: PCI group versus CABG group.

Baseline characteristics and medications during the index hospitalization: PCI group versus CABG group.</p

Clinical outcomes: PCI group versus CABG group in patients with two-vessel disease who underwent multi-vessel revascularization including LAD.

(DOCX)</p