Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea.
Yonsei Med J. 2020 Jul;61(7):597-605. doi: 10.3349/ymj.2020.61.7.597.
Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice.
From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)].
Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter ≤3.0 mm, total stented length ≥28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69-1.68; =0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72-2.07; =0.453). Major bleeding rates were comparable between the two groups.
In patients undergoing percutaneous coronary intervention, indefinite use of DAPT does not show superior outcomes to those of guideline-DAPT. Major bleeding rates are also similar.
尽管目前的指南建议在药物洗脱支架（DES）植入后，双抗血小板治疗（DAPT）持续时间最长可达 12 个月，但在实际临床实践中，DAPT 常常被延长。
我们从韩国多中心经皮冠状动脉介入治疗团队注册中心共入选了 1414 例 DES 植入后 DAPT 持续时间超过 3 年的患者（延长 DAPT 组），并在指数操作后 36 个月进行了里程碑分析。我们评估了延长 DAPT 的决定因素和长期结局，并比较了延长 DAPT 组与指南 DAPT 组（DES 植入后 1 年内的 DAPT <1 年，n=1273）主要不良心血管和脑血管事件（MACCE）的发生情况，定义为全因死亡、心肌梗死、支架血栓形成和卒中的复合终点。
多变量分析表明，急性冠状动脉综合征的发生是延长 DAPT 使用的最重要的临床决定因素。分叉病变、支架直径≤3.0mm、总支架长度≥28mm 和第一代 DES 的使用也是显著的血管造影和操作决定因素。在粗分析中，延长 DAPT 组与指南 DAPT 组的 MACCE 发生率相似（风险比[HR]，1.08；95%置信区间[CI]，0.69-1.68；=0.739），在倾向评分匹配后也相似（HR，1.22；95%CI，0.72-2.07；=0.453）。两组大出血发生率相似。
在接受经皮冠状动脉介入治疗的患者中，无限期使用 DAPT 并不比指南指导的 DAPT 更具优势。大出血发生率也相似。
