Extended-Duration DAPT Reduces Mortality, Event Rate in TWILIGHT-like Patients

Haoyu Wang, MD, PhD

Using a TWILIGHT-like cohort, a team of investigators from multiple institutions in China is shedding further light on the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS).

Presented at the Society of Coronary Angiography and Interventions (SCAI) 2021 Scientific Sessions, the study highlights the improved outcomes and comparable rates of bleeding events were achieved with DAPT lasting longer than 12 months compared with shorter DAPT in ACS patients.

“Not only did we see long-term DAPT was associated with a lower risk of a major cardiovascular event without an increase in bleeding events, but it could be considered an effective strategy to balance the risk for bleeding and ischemia in high-risk patients with ACS,” said Haoyu Wang, MD, PhD, a cardiovascular resident at the Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, in a statement. "Our results reinforce prolonged DAPT in patients with acute coronary syndrome without excessive risk of bleeding should remain the standard of care."

With a recent emphasis placed on reducing the duration of antiplatelet therapy following PCI, Wang and a team of colleagues sought to explore the risk-benefit relationship of extended-duration DAPT compared to short-term DAPT in high-risk “TWILIGHT-like” patients. To do so, investigators designed the current study as an assessment of patients identified within the Fuwai PCI Registry.

A prospective registry containing data related to more than 10000 patients, investigators were able to identify a cohort of 4875 patients who met the criteria of at least one clinical and one angiographic feature required for inclusion in the TWILIGHT trial and were event-free at 12 months post-PCI. Using this cohort, investigators hoped to determine the efficacy and safety of extended-duration DAPT compared against short-term DAPT.

For the purpose of analysis, investigators defined the primary outcome as a composite of all-cause death, myocardial infarction, or stroke at 30 months. Investigators also included incidence of Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding was chosen as the secondary outcome of interest.

Overall, 3335 patients received DAPT for longer than 12 months following PCI and 1540 received DAPT for 12 months or less. The primary outcome occurred in 1.5% of patients with extended DAPT and 3.8% of patients with short-term DAPT.

As part of their study, investigators performed multiple analyses, including a multivariable analysis and a propensity score-matched analysis. In these analyses, investigators found extended duration DAPT was associated with a significant reduction in the study’s primary outcome ([aHR, 0.374; 95% CI, 0.256-0.548]; [matched HR, 0.361; 95% CI, 0.221-0.590]).

When assessing safety, results indicated there was no significant difference among rates of BARC type 2, 3, or 5 bleeding between the groups, with rates of 0.9% and 1.3% in the extended-duration and short-term DAPT groups, respectively. Investigators pointed out lower hazard ratios for bleeding events were observed for extended-duration DAPT compared to short-term in both adjusted and propensity score-matched analyses ([aHR, 0.668; 95% CI, 0.379-1.178]; [matched HR, 0.721; 95% CI, 0.369-1.410]). Investigators also pointed out the apparent effects of extended-duration DAPT were consistent across subgroups of patients with 1-3, 4-5, or 6-9 risk factors.

This study, “Establishing the Optimal Duration of DAPT After PCI in High-Risk TWILIGHT-like patients with Acute Coronary Syndrome,“ was presented at SCAI 2021.