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The Association of CHADS-P2A2RC Risk Score With Clinical Outcomes in Patients Taking P2Y12 Inhibitor Monotherapy
Pil Sang Song1, Seok-Woo Seong1, Ji-Yeon Kim1
1Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
Insights
P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) is safe and effective for high-risk patients undergoing percutaneous coronary intervention (PCI). This approach reduces bleeding events without increasing ischemic risks compared to prolonged DAPT.
Area of Science:
- Cardiology
- Interventional Cardiology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) duration after percutaneous coronary intervention (PCI) is debated, with concerns about early aspirin cessation in high-risk patients.
- The CHADS-P2A2RC score stratifies ischemic risk, guiding antiplatelet therapy decisions.
Purpose of the Study:
- To evaluate the efficacy and safety of P2Y12 inhibitor monotherapy versus prolonged DAPT (≥12 months) after 3-month DAPT.
- To assess these strategies based on ischemic risk stratification using the CHADS-P2A2RC score in patients post-PCI.
Main Methods:
- A sub-study of the SMART-CHOICE trial involving randomized antiplatelet strategies.
- Patients were stratified into low, moderate, and high risk using the CHADS-P2A2RC score.
- Primary outcome: Major adverse cardiac and cerebral event (MACCE) – all-cause death, myocardial infarction, or stroke.
Main Results:
- High CHADS-P2A2RC risk score group showed the highest MACCE incidence (12.1%).
- P2Y12 inhibitor monotherapy demonstrated reduced Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding compared to prolonged DAPT.
- No significant increase in MACCE risk was observed with P2Y12 inhibitor monotherapy across all risk strata.
Conclusions:
- The CHADS-P2A2RC risk score effectively identifies patients at high risk for ischemic events.
- P2Y12 inhibitor monotherapy after 3-month DAPT is a safe and effective strategy, particularly for high-risk patients, reducing bleeding without compromising ischemic event prevention.
Background And Objectives:
Concerns remain that early aspirin cessation may be associated with potential harm in subsets at high risk of ischemic events. This study aimed to assess the effects of P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) vs. prolonged DAPT (12-month or longer) based on the ischemic risk stratification, the CHADS-P2A2RC, after percutaneous coronary intervention (PCI).
Methods:
This was a sub-study of the SMART-CHOICE trial. The effect of the randomized antiplatelet strategies was assessed across 3 CHADS-P2A2RC risk score categories. The primary outcome was a major adverse cardiac and cerebral event (MACCE), a composite of all-cause death, myocardial infarction, or stroke.
Results:
Up to 3 years, the high CHADS-P2A2RC risk score group had the highest incidence of MACCE (105 [12.1%], adjusted hazard ratio [HR], 2.927; 95% confidence interval [CI], 1.358-6.309; p=0.006) followed by moderate-risk (40 [1.4%], adjusted HR, 1.786; 95% CI, 0.868-3.674; p=0.115) and low-risk (9 [0.5%], reference). In secondary analyses, P2Y12 inhibitor monotherapy reduced the Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding without increasing the risk of MACCE as compared with prolonged DAPT across the 3 CHADS-P2A2RC risk strata without significant interaction term (interaction p for MACCE=0.705 and interaction p for BARC types 2, 3, or 5 bleeding=0.055).
Conclusions:
The CHADS-P2A2RC risk score is valuable in discriminating high-ischemic-risk patients. Even in such patients with a high risk of ischemic events, P2Y12 inhibitor monotherapy was associated with a lower incidence of bleeding without increased risk of ischemic events compared with prolonged DAPT.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02079194.
