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P2Y12 Inhibitor Monotherapy vs. Dual Antiplatelet Therapy After Complex PCI

Compared with dual antiplatelet therapy (DAPT) for 3 months after complex percutaneous coronary intervention (PCI), 1 month of P2Y12 inhibitor monotherapy produced similar rates of fatal and ischemic events and lower risk of major bleeding, researchers report based on an analysis of patient-level data from 5 randomized controlled trials. Complexity of the PCI did not affect the results.

The pooled data produced these results based on a primary efficacy endpoint of all-cause mortality, myocardial infarction, and stroke and a key safety endpoint of Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding: “Of 22,941 patients undergoing PCI from 5 trials, 4,685 (20.4%) with complex PCI had higher rates of ischemic events. The primary efficacy endpoint was similar between P2Y12 inhibitor monotherapy and DAPT among patients with complex PCI (HR: 0.87; 95% CI: 0.64-1.19) and noncomplex PCI (HR: 0.91; 95% CI: 0.76-1.09; Pinteraction = 0.770). The treatment effect was consistent across all the components of the complex PCI definition. Compared with DAPT, P2Y12 inhibitor monotherapy consistently reduced BARC 3 or 5 bleeding in complex PCI (HR: 0.51; 95% CI: 0.31-0.84) and noncomplex PCI patients (HR: 0.49; 95% CI: 0.37-0.64; Pinteraction = 0.920).”

Editorial: An accompanying editorialist discusses whether it is time to adopt a strategy of initial short course of DAPT followed by P2Y12 inhibitor monotherapy: “The present data raise the possibility that such a de-escalation strategy to P2Y12 inhibitor monotherapy should perhaps be the default strategy, including for complex PCI, and not reserved for use only in those at perceived high bleeding risk.”

Source: Journal of the American College of Cardiology