Risk-Benefit Analysis in Treatment Selection in CAD

Deepak Bhatt, MD, MPH: Amy, what do you think of that concept? Of course, there’s a stent-associated risk, and many times the interventionalists will have strong feelings about that. Actually, I always try to indicate in my notes that I think the patient should be on DAPT [dual antiplatelet therapy]. And this flavor of DAPT, this intensity of DAPT, whether clopidogrel, prasugrel, ticagrelor, for this long, and if point, if there’s no bleeding, this is what I think you should do. Thus, I tend to try to provide as much advice and guidance as I can regarding the procedure I did in the stent. But then beyond that, that patient is at risk, even if the stent is totally bulletproof for the next 20 years. Obviously, they at least had coronary artery disease [CAD] that was severe enough that I put a stent in, but then they might have other things going on; diabetes, chronic kidney disease, and cardiovascular disease. How do you separate those 2 risks in terms of how you think about antithrombotic strategies?

Amy Pollak, MD: Well, it’s a great question, and I love the highway and potholes analogy—that’s fantastic. I think, as we’re looking at this concerning the kind of the pros and cons and this bleeding versus thrombotic risk, my father’s an environmental lawyer and he raised me even pre-medicine to think about things as pro/con list. My whole life is sort of this pro/con list for every more major decision. But this part of how we approach things was how I kind of see the world. And that’s what I talk about with patients. I sort of envision sort of the scale of justice between the bleeding risk and the thrombotic risk. And thus, if we have somebody who’s had a recent stent for a myocardial infarction, as Eric Secemsky said, these patients are at a really high future risk of events because of how they presented. And thus, if it becomes harder if you’re at a high thrombotic risk and also a high bleeding risk, then that’s the most difficult situation. But I think our path is certainly more clear if somebody’s at a high thrombotic risk because they’ve had a recent acute limb event at myocardial infarction and they’re at low bleeding risk in terms of what we have to offer with regards to that dual pathway inhibition.

And I think when we look at things like the COMPASS [Cardiovascular Outcomes for People using Anticoagulation Strategies] trial, particularly COMPASS-PAD, and Marc Bonaca has been really involved with this, that it was striking to me that there was an absolute risk reduction of about 5%, I believe, in patients who had PAD [peripheral artery disease] and who had a prior intervention, peripheral intervention, who then were treated with the dual pathway inhibition with low-dose rivaroxaban [Xarelto] plus aspirin. And that’s a big act. Hence, much of what we struggled with over the years with the DAPT trial, we look at the individual patients as we’re doing that risk and benefit analysis. It’s like a 1% absolute risk reduction. And we were really splitting hairs about this, but this is a big absolute risk reduction.

Deepak Bhatt, MD, MPH:In high-risk patients, the benefits and absolute risk reductions really get amplified.

Transcript Edited for Clarity