Prevalence and predictors of dual antiplatelet therapy prolongation beyond one year in patients with acute coronary syndrome

October Prevalence and predictors of dual antiplatelet therapy prolongation beyond one year in patients with acute coronary syndrome Giuseppe Patti 0 1 2 Ilaria Cavallari 0 1 2 Emilia Antonucci 0 2 Paolo Calabrò 0 2 Plinio Cirillo 0 2 5 Paolo Gresele 0 2 4 Gualtiero Palareti 0 2 Vittorio Pengo 0 2 Pasquale Pignatelli 0 2 3 Elisabetta Ricottini 0 1 2 Rossella Marcucci 0 2 6 0 following interests: GiPa: speaker/consultant/ advisory board for Bayer , Boehringer-Ingelheim, BMS-Pfizer, Daiichi Sankyo, Astra Zeneca, PIAM, Sanofi, AMGEN, Sigma-Tau, Malesci and MSD. VP: Advisory Board/Lecure fees for Bayer HealthCare 1 Campus Bio-Medico University of Rome , Rome, Italy, 2 Arianna Anticoagulazione Foundation, Bologna , Italy , 3 Division of Cardiology, Monaldi Hospital and "Luigi Vanvitelli" University of Campania , Naples , Italy 2 Editor: Andreas SchaÈfer , Medizinische Hochschule Hannover , GERMANY 3 Department of Internal Medicine and Medical Specialties, La Sapienza University of Rome , Rome , Italy 4 Department of Medicine, Division of Internal and Cardiovascular Medicine, University of Perugia , Perugia , Italy , 6 Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua , Padua , Italy 5 Department of Advanced Biomedical Sciences, School of Medicine, "Federico II" University , Naples , Italy 6 Department of Experimental and Clinical Medicine, Center for Atherothrombotic diseases, University of Florence , Florence , Italy There are limited real-world data on prevalence and predictors of dual antiplatelet therapy (DAPT) prolongation beyond one year after acute coronary syndrome (ACS). We have explored such issue in the START ANTIPLATELET Registry, which is a prospective, observational, multicenter, Italian registry performed in seven Italian cardiology institutions including patients admitted for ACS and followed up to one year. Out of a total population of 840 ACS patients, 596 patients had completed 12-month follow-up being on DAPT. Decision to prolong DAPT beyond one year was taken in 79 patients (13%), whereas in 517 patients DAPT was stopped. The strongest predictors of DAPT continuation were a new cardiovascular events after the index admission event (OR 3.3, 95% CI 1.4±7.7), no bleeding complications (OR 3.2, 95% CI 1.2±8.3) and no anemia during one-year follow-up (OR 2.6, 95% CI 1.1±5.9); other independent predictors were renal failure (OR 2.5, 95% CI 1.3±5.0) and peripheral artery disease (OR 1.8, 95% CI 1.1±3.0). The choice of DAPT prolongation was not correlated with younger ager, presence of diabetes mellitus, coronary angioplasty as initial treatment strategy or type of implanted stent (drug-eluting vs bare metal). In conclusion, this study provides a real-world snapshot on the factors influencing the option to continue DAPT beyond one year after ACS; a low bleeding risk seems to influence the choice to pro- - Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The authors received no funding for this work. long DAPT more than a high ischemic risk. Introduction Current guidelines on myocardial infarction (MI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS) recommend as routine strategy the use of dual antiplatelet Daiichi Sankyo, BMS-Pfizer and Werfen Group; RM: Honoraria for lectures and consulting fees from: Bayer, Boehringer Ingelheim, Pfizer, DaichiSankyo, Astra Zeneca. IC, EA, PaCa, PlCi, PG, GuPa, PP, ER: no disclosure. This does not alter our adherence to PLOS ONE policies on sharing data and materials. therapy (DAPT, aspirin plus a P2Y12 inhibitor) up to one year after the index event and then to continue with a single-drug approach, usually aspirin.[1±3] However, large-sized registries have shown that at least 20% of patients who are event-free at one year post-MI and receive a single antiplatelet treatment will suffer a new cardiovascular event within five years.[ 4,5 ] On the other hand, sub-analyses from controlled randomized trials had suggested that DAPT prolongation beyond one year after ACS is associated with reduction of ischemic cardiovascular complications;[ 6,7 ] more recently, the randomized PEGASUS and DAPT trials have demonstrated a decrease of major adverse cardiovascular events (MACE) with prolonged DAPT after MI or coronary stenting, respectively, compared to aspirin alone, at the price of a significant increase of non-fatal bleeding.[ 8,9 ] Thus, at one year after ACS it appears crucial to carefully consider and balance on an individual basis the ischemic and bleeding risks and tailor a long-term antithrombotic strategy approach accordingly. Of note, the 2015 Guidelines of the European Society of Cardiology on NSTE-ACS indicate the possibility to use in selected patients a P2Y12 inhibitor in addition to aspirin beyond one year with class of recommendation IIb and level of evidence B.[1] To date, there are limited real-world data on the proportion of pat (...truncated)