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Abbreviated Antiplatelet Therapy After Coronary Stenting in Patients With Myocardial Infarction at High Bleeding Risk
Pieter C Smits1, Enrico Frigoli2, Pascal Vranckx3
1Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands.
Insights
For high bleeding risk patients after coronary stenting, a 1-month dual antiplatelet therapy (DAPT) regimen is as effective as longer DAPT and significantly reduces bleeding events. This abbreviated approach offers a safer alternative for managing acute myocardial infarction.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Optimal duration of antiplatelet therapy (APT) post-coronary stenting in high bleeding risk (HBR) patients with acute coronary syndrome is uncertain.
- Patients with HBR require careful consideration of bleeding versus ischemic event risks.
Purpose of the Study:
- To evaluate the safety and efficacy of an abbreviated APT regimen following coronary stenting in HBR patients.
- To compare an abbreviated APT strategy against a non-abbreviated strategy in patients with acute or recent myocardial infarction.
Main Methods:
- The MASTER DAPT trial randomized 4,579 HBR patients after 1 month of DAPT.
- Patients received either abbreviated APT (11 months single APT or 5 months with oral anticoagulants) or non-abbreviated APT (minimum 3 months DAPT).
- Outcomes included net adverse clinical events (NACE), major adverse cardiac and cerebral events (MACCE), and Bleeding Academic Research Consortium (BARC) bleeding.
Main Results:
- Abbreviated APT did not differ in NACE or MACCE rates compared to non-abbreviated APT in patients with or without acute/recent myocardial infarction.
- BARC 2, 3, or 5 bleeding was significantly reduced with the abbreviated APT strategy in both patient groups.
- P-interaction values indicated no significant difference in treatment effect modification between subgroups.
Conclusions:
- A 1-month DAPT strategy is safe and effective for HBR patients with acute or recent myocardial infarction.
- This abbreviated DAPT approach leads to similar ischemic event rates while substantially lowering bleeding complications.
- The findings support shorter DAPT durations for selected HBR populations to mitigate bleeding risk.
Background:
The optimal duration of antiplatelet therapy (APT) after coronary stenting in patients at high bleeding risk (HBR) presenting with an acute coronary syndrome remains unclear.
Objectives:
The objective of this study was to investigate the safety and efficacy of an abbreviated APT regimen after coronary stenting in an HBR population presenting with acute or recent myocardial infarction.
Methods:
In the MASTER DAPT trial, 4,579 patients at HBR were randomized after 1 month of dual APT (DAPT) to abbreviated (DAPT stopped and 11 months single APT or 5 months in patients with oral anticoagulants) or nonabbreviated APT (DAPT for minimum 3 months) strategies. Randomization was stratified by acute or recent myocardial infarction at index procedure. Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes events (NACE); major adverse cardiac and cerebral events (MACCE); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding.
Results:
NACE and MACCE did not differ with abbreviated vs nonabbreviated APT regimens in patients with an acute or recent myocardial infarction (n = 1,780; HR: 0.83; 95% CI: 0.61-1.12 and HR: 0.86; 95% CI: 0.62-1.19, respectively) or without an acute or recent myocardial infarction (n = 2,799; HR: 1.03; 95% CI: 0.77-1.38 and HR: 1.13; 95% CI: 0.80-1.59; Pinteraction = 0.31 and 0.25, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding was significantly reduced in patients with or without an acute or recent myocardial infarction (HR: 0.65; 95% CI: 0.46-0.91 and HR: 0.71; 95% CI: 0.54-0.92; Pinteraction = 0.72) with abbreviated APT.
Conclusions:
A 1-month DAPT strategy in patients with HBR presenting with an acute or recent myocardial infarction results in similar NACE and MACCE rates and reduces bleedings compared with a nonabbreviated DAPT strategy. (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).
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