Tailoring Dual Antiplatelet Therapy for the Complex PCI Patient: Current Status and Perspectives
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INVITED REVIEW ARTICLE
Tailoring Dual Antiplatelet Therapy for the Complex PCI Patient: Current Status and Perspectives Despoina-Rafailia Benetou 1 & Ioannis Andreou 1 & Charalampos Varlamos 1 & Dimitrios Alexopoulos 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Dual antiplatelet therapy (DAPT) duration in patients undergoing percutaneous coronary intervention (PCI) has long been considered a matter of controversy. Complex-PCI (C-PCI) is considered to be associated with an increased ischemic risk that tends to be greater with progressively higher procedural complexity. Thus, with a view to balance ischemic versus bleeding risks, high complexity of PCI intuitively represents an advocate of prolonged DAPT duration. However, the optimal DAPT strategy in this high ischemic risk subset of patients remains unclear, a fact that is exacerbated by the absence of a universal definition of C-PCI, resulting in a significant between-study heterogeneity. The aim of this review is to highlight the increased risks associated with C-PCI, compare long- versus short-term DAPT regimens regarding safety and efficacy endpoints as well as investigate outcomes in special C-PCI cohorts, such as patients with bifurcation, left main or chronic total occlusion lesions. Furthermore, controversial issues, such as antithrombotic regimens in C-PCI patients with atrial fibrillation, and future perspectives are addressed. Keywords Complex PCI . Antiplatelet drugs . Bifurcation . CTO . Left main
Introduction Dual antiplatelet therapy (DAPT) remains the cornerstone of treatment in patients undergoing percutaneous coronary intervention (PCI). Aiming to balance ischemic and bleeding complications’ risk, duration of DAPT, based mainly on clinical settings, patient’s characteristics and risk factors, varies [1]. Alongside these factors, complexity of PCI procedure has been suggested to play a role in decision making, with the optimal duration of DAPT in this subset of patients remaining uncertain [2]. Although there is no universal definition (Table 1), complex PCI (C-PCI) usually includes bifurcation with 2 stents implanted, ≥ 3 stents implanted, ≥ 3 lesions treated, total stent length > 60 mm or treatment of a chronic total occlusion (CTO) [1]. Οther procedural characteristics, such as left main (LM) or proximal left anterior descending (LAD) artery
* Dimitrios Alexopoulos [email protected] 1
2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 12462 Athens, Greece
location, vein bypass graft PCI, bifurcation lesion with side branch ≥ 2.5 mm, lesion length ≥ 30 mm, thrombuscontaining lesion, or rotational atherectomy use for severely calcified lesions, have been used to characterize a C-PCI as well (Fig. 1) [5]. Along with an increasing number of patients undergoing PCI with high-risk clinical features, such as advanced age, diabetes, renal failure, poor left ventricular function, or need for concurrent oral anticoagulation (
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