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Impact of preprocedural coronary flow grade on duration of dual antiplatelet therapy in acute myocardial infarction.

ABSTRACT: We investigated the impact of pre-percutaneous coronary intervention (pre-PCI) thrombolysis in myocardial infarction (TIMI) flow grade (pre-TIMI) on 3-month (3-mo) and 12-mo of dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI). This was a post hoc analysis of the TICO trial. A total of 2083 patients with AMI (pre-TIMI 0/1: n = 1143; pre-TIMI 2/3: n = 940) were evaluated. The primary outcome was the occurrence of net adverse clinical events (NACE), defined as a composite of TIMI major bleeding and major adverse cardiac and cerebrovascular events (MACCE) within 12-mo following PCI. The secondary outcomes were the occurrence of the individual components of TIMI bleedings and MACCE. In the pre-TIMI 0/1 group, the primary and second outcomes were not significantly different between the 3-mo and 12-mo DAPT groups. However, in the pre-TIMI 2/3 group, the occurrences of TIMI minor (adjusted hazard ratio [aHR]: 0.294; p = 0.016) and major or minor bleeding (aHR: 0.483; p = 0.014) on intention-to-treat analysis were significantly higher in the 12-mo than in the 3-mo DAPT group. The occurrence of MACCE was similar between the two groups. A higher bleeding tendency in 12-mo DAPT compared with 3-mo DAPT was more obvious in the pre-TIMI 2/3 group than in the pre-TIMI 0/1 group.Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02494895.

SUBMITTER: Kim YH

PROVIDER: S-EPMC8175426 | biostudies-literature | 2021 Jun

REPOSITORIES: biostudies-literature

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Impact of preprocedural coronary flow grade on duration of dual antiplatelet therapy in acute myocardial infarction.

Kim Yong Hoon YH Her Ae-Young AY Kim Byeong-Keuk BK Hong Sung-Jin SJ Ahn Chul-Min CM Kim Jung-Sun JS Ko Young-Guk YG Choi Donghoon D Hong Myeong-Ki MK Jang Yangsoo Y

Scientific reports 20210603 1

We investigated the impact of pre-percutaneous coronary intervention (pre-PCI) thrombolysis in myocardial infarction (TIMI) flow grade (pre-TIMI) on 3-month (3-mo) and 12-mo of dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI). This was a post hoc analysis of the TICO trial. A total of 2083 patients with AMI (pre-TIMI 0/1: n = 1143; pre-TIMI 2/3: n = 940) were evaluated. The primary outcome was the occurrence of net adverse clinical events (NACE), defined as a c ...[more]

PMID: 34083627

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Project description:BackgroundThe benefits and risks of prolonged dual antiplatelet therapy may be different for patients with acute myocardial infarction (MI) compared with more stable presentations.ObjectivesThis study sought to assess the benefits and risks of 30 versus 12 months of dual antiplatelet therapy among patients undergoing coronary stent implantation with and without MI.MethodsThe Dual Antiplatelet Therapy Study, a randomized double-blind, placebo-controlled trial, compared 30 versus 12 months of dual antiplatelet therapy after coronary stenting. The effect of continued thienopyridine on ischemic and bleeding events among patients initially presenting with versus without MI was assessed. The coprimary endpoints were definite or probable stent thrombosis and major adverse cardiovascular and cerebrovascular events (MACCE). The primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries) moderate or severe bleeding.ResultsOf 11,648 randomized patients (9,961 treated with drug-eluting stents, 1,687 with bare-metal stents), 30.7% presented with MI. Between 12 and 30 months, continued thienopyridine reduced stent thrombosis compared with placebo in patients with and without MI at presentation (MI group, 0.5% vs. 1.9%, p < 0.001; no MI group, 0.4% vs. 1.1%, p < 0.001; interaction p = 0.69). The reduction in MACCE for continued thienopyridine was greater for patients with MI (3.9% vs. 6.8%; p < 0.001) compared with those with no MI (4.4% vs. 5.3%; p = 0.08; interaction p = 0.03). In both groups, continued thienopyridine reduced MI (2.2% vs. 5.2%, p < 0.001 for MI; 2.1% vs. 3.5%, p < 0.001 for no MI; interaction p = 0.15) but increased bleeding (1.9% vs. 0.8%, p = 0.005 for MI; 2.6% vs. 1.7%, p = 0.007 for no MI; interaction p = 0.21).ConclusionsCompared with 12 months of therapy, 30 months of dual antiplatelet therapy reduced the risk of stent thrombosis and MI in patients with and without MI, and increased bleeding. (The Dual Antiplatelet Therapy Study [The DAPT Study]; NCT00977938).

Project description:ImportanceDespite antirestenotic efficacy of coronary drug-eluting stents (DES) compared with bare metal stents (BMS), the relative risk of stent thrombosis and adverse cardiovascular events is unclear. Although dual antiplatelet therapy (DAPT) beyond 1 year provides ischemic event protection after DES, ischemic event risk is perceived to be less after BMS, and the appropriate duration of DAPT after BMS is unknown.ObjectiveTo compare (1) rates of stent thrombosis and major adverse cardiac and cerebrovascular events (MACCE; composite of death, myocardial infarction, or stroke) after 30 vs 12 months of thienopyridine in patients treated with BMS taking aspirin and (2) treatment duration effect within the combined cohorts of randomized patients treated with DES or BMS as prespecified secondary analyses.Design, setting, and participantsInternational, multicenter, randomized, double-blinded, placebo-controlled trial comparing extended (30-months) thienopyridine vs placebo in patients taking aspirin who completed 12 months of DAPT without bleeding or ischemic events after receiving stents. The study was initiated in August 2009 with the last follow-up visit in May 2014.InterventionsContinued thienopyridine or placebo at months 12 through 30 after stent placement, in 11,648 randomized patients treated with aspirin, of whom 1687 received BMS and 9961 DES.Main outcomes and measuresStent thrombosis, MACCE, and moderate or severe bleeding.ResultsAmong 1687 patients treated with BMS who were randomized to continued thienopyridine vs placebo, rates of stent thrombosis were 0.5% vs 1.11% (n = 4 vs 9; hazard ratio [HR], 0.49; 95% CI, 0.15-1.64; P = .24), rates of MACCE were 4.04% vs 4.69% (n = 33 vs 38; HR, 0.92; 95% CI, 0.57-1.47; P = .72), and rates of moderate/severe bleeding were 2.03% vs 0.90% (n = 16 vs 7; P = .07), respectively. Among all 11,648 randomized patients (both BMS and DES), stent thrombosis rates were 0.41% vs 1.32% (n = 23 vs 74; HR, 0.31; 95% CI, 0.19-0.50; P < .001), rates of MACCE were 4.29% vs 5.74% (n = 244 vs 323; HR, 0.73; 95% CI, 0.62-0.87; P < .001), and rates of moderate/severe bleeding were 2.45% vs 1.47% (n = 135 vs 80; P < .001).Conclusions and relevanceAmong patients undergoing coronary stent placement with BMS and who tolerated 12 months of thienopyridine, continuing thienopyridine for an additional 18 months compared with placebo did not result in statistically significant differences in rates of stent thrombosis, MACCE, or moderate or severe bleeding. However, the BMS subset may have been underpowered to identify such differences, and further trials are suggested.Trial registrationclinicaltrials.gov Identifier: NCT00977938.

Project description:BackgroundTo assess single-photon emission computed tomography cadmium-zinc-telluride (SPECT CZT)-derived myocardial blood flow (MBF) flow reserve (MFR) and flow difference (FD) in patients with acute myocardial infarction (AMI) and to compare this data with serum cardiac troponin and cardiac magnetic resonance (CMR) findings.MethodsA total of 31 patients with AMI underwent invasive coronary angiography (ICA), serial high-sensitivity serum cardiac troponin I (cTnI) measurement, and CZT SPECT with visual and quantitative (MBF, MFR, and FD) perfusion parameters, and contrast-enhanced CMR. All patients with AMI were divided into two groups: (1) with non-obstructive coronary arteries (MINOCA), n = 10; (2) with obstructive coronary artery disease (MICAD), n = 21.ResultsThe values of SSS and SRS were significantly (p < 0.01) higher whereas global stress MBF, MFR significantly lower in patients with MICAD as compared to MINOCA - 5.0 (3.0; 5.0) vs. 9.0 (5.0; 13.0); 2.0 (1.0; 3.0) vs. 6.0 (3.0; 11.0); 2.02 (1.71; 2.37) vs. 0.86 (0.72; 1.02) ml/min/g; and 2.61 (2.23; 3.14) vs. 1.67 (1.1; 1.9), respectively. Stress MBF correlated with cTnI at 24 h and day 4: ρ = -0.39; p = 0.03 and ρ = -0.47; p = 0.007, respectively. FD correlated with cTnI at 24 h and day 4: ρ = -0.39; p = 0.03 and ρ = -0.46; p = 0.009. CMR analysis showed that infarct size, MVO and myocardial edema in patients with MICAD were significantly (< 0.05) higher as compared to MINOCA: 19.4 (10.4; 29.7) vs. 1.8 (0.0; 6.9); 0.1 (0.0; 0.7) vs. 0.0 (0.0; 0.0) and 19.5 (12.0;30.0) vs. 3.0 (0.0; 12.0), respectively. According to vessel-based analysis of CMR data, acute myocardial injury (defined as late gadolinium enhancement and myocardial edema) was observed more frequently in patients with MICAD compared to MINOCA: 34(37%) vs. 5(5%) p = 0.005, respectively. The values of regional stress MBF, MFR and FD were significantly decreased in LV territories characterized by myocardial injury compared to those without: 0.98 (0.73; 1.79) vs. 1.33 (0.94; 2.08) p < 0.01, 1.64 (1.0; 2.36) vs. 2.0 (1.53; 2.89) p < 0.01 and 0.33 (0.05; 0.57) vs. 0.56 (0.36; 1.32) p> 0.01, respectively.ConclusionIn patients with AMI, SPECT CZT-derived flow measures were associated with the high-sensitivity troponin I as well as the extent of edema, microvascular obstruction, and infarct size detected by CMR. On the regional level, quantitative SPECT CZT measures were significantly lower in vessel territories characterized by myocardial injury.

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Impact of preprocedural coronary flow grade on duration of dual antiplatelet therapy in acute myocardial infarction.

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Impact of preprocedural coronary flow grade on duration of dual antiplatelet therapy in acute myocardial infarction.

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