Clinical question: Can the dual-antiplatelet therapy scoring system be used to determine which patients undergoing percutaneous coronary intervention (PCI) would benefit from prolonged (24 months) DAPT?
Background: Prolonged DAPT therapy has been estimated to prevent 8 myocardial infarctions per 1,000 persons treated for 1 year but at the cost of 6 major bleeding events with no clear mortality benefit. Given these trade-offs, the DAPT score could be used to identify patients who would benefit or would be harmed from prolonged DAPT. The safety and efficacy of DAPT duration as guided by the DAPT score has not been assessed outside the derivation cohort. This study applied the DAPT score to the PRODIGY trial patients to evaluate safety and outcomes of DAPT for 24 months versus a less than 6-month regimen.
Study design: Retrospective use of the DAPT score in PRODIGY patients.
Setting: PCI patients in PRODIGY trial.
Synopsis: In the original derivation cohort, a low DAPT score of less than 2 identified patients whose bleeding risks outweigh ischemic benefits and a high score above 2 identifies patients for whom ischemic benefits outweigh bleeding risks. When the DAPT score was applied to the 1,970 patients enrolled in PRODIGY, 55% had a low score and 45% had a high score. The primary efficacy outcomes of death, MI, and stroke were evaluated as well as primary safety outcomes of bleeding according to the Bleeding Academic Research Consortium definition. The reduction in the primary efficacy outcomes with 24-month vs. 6-month DAPT was greater in patients with a high DAPT score but only in the older paclitaxel-eluting stents. Since these stents have mostly fallen out of favor, there are some limitations to the applicability of the study findings. The study also provides support for 6 months of DAPT for patients with a DAPT score of less than 2.
Bottom line: For patients who underwent PCI with a DAPT score of less than 2, the risk for bleeding appears to be higher than are the ischemic benefits, while patients who had a high DAPT score of greater than 2 with a first-generation stent, the ischemic benefits of prolonged DAPT seemed to outweigh the bleeding risks.
Citation: Piccolo R et al. Use of the dual-antiplatelet therapy score to guide treatment duration after percutaneous coronary intervention. Ann Intern Med. 2017 Jul 4;167(1):17-25
Dr. Setji is a hospitalist and medical director, Duke University Hospital.