Clinical question: Does P2Y12 inhibitor monotherapy after one to three months of dual antiplatelet therapy (DAPT) improve clinical decrease in major bleeding risk without increasing ischemic risk in patients who have received complex percutaneous coronary intervention (PCI)?
Background: DAPT puts patients at a high risk of bleeding events. Recent studies have demonstrated similar ischemic outcomes after switching to P2Y12 inhibitor monotherapy (such as clopidogrel) after one to three months of DAPT with decreased major bleeding events in the setting of simple PCI. It is unknown whether this outcome holds true for complex PCI. Complex PCI is defined as three vessels treated, at least three stents implanted, at least three lesions treated, bifurcation with two stents implanted, total stent length >60mm, or stenting of a chronic total occlusion.
Study design: Evaluation of pooled patient data from five separate trials
Setting: Pooled patient-level data from five randomized controlled trials
Synopsis: Using pooled, patient-level data, 4,685 patients who received complex PCI were evaluated for the effect of DAPT de-escalated to P2Y12 inhibitor after one to three months versus standard DAPT therapy. Primary efficacy outcomes were all-cause mortality, myocardial infarction, and stroke. The safety endpoint was Bleeding Academic Research Consortium 3 or 5 bleeding. All primary efficacy endpoints were similar between the two groups and the treatment effect was consistent across all components of the complex PCI definition. P2Y12 inhibitor monotherapy consistently reduced bleeding outcomes in complex PCI (HR, 0.51,;95% CI, 0.31-0.84).
Hospitalists should be aware that patients, especially patients struggling with adverse bleeding, may not need to be on DAPT if they are more than one month from coronary intervention regardless of intervention complexity.
Bottom line: P2Y12 inhibitor monotherapy one to three months after DAPT for complex PCI decreased bleeding risk without increasing ischemic risk as compared with DAPT.
Citation: Gragnano F, et al. P2Y12 Inhibitor monotherapy or dual antiplatelet therapy after complex percutaneous coronary interventions. J Am Coll Cardiol. 2023;81(6):537-52.
Dr. Imber is an assistant professor in the department of internal medicine, division of hospital medicine, and director of the internal medicine simulation education and hospitalist procedural certification at the University of New Mexico, Albuquerque, N.M.