BOSTON – When patients with cardiovascular disease have stents placed in narrowed coronary arteries to ensure that blood is delivered to the heart, they typically receive a combination of antiplatelet drugs for many months (up to 2.5 years) after surgery to prevent blood clots from forming in the stents. A recent analysis published in the journal Circulation and led by researchers at Massachusetts General Hospital (MGH) and Beth Israel Deaconess Medical Center indicates that this practice may be outdated and should not be followed for most patients today.
The prolonged antiplatelet drug regimen is based on results from a clinical trial—called the Dual Antiplatelet Therapy (DAPT) Study—that enrolled patients 10 years ago and whose results were reported in the New England Journal of Medicine in 2014. In the trial, long-term use of the drugs prevented clots within stents and reduced the risk of major adverse cardiovascular and cerebrovascular events. Today’s patients may be different from those who participated in the trial, however, and stent technology has improved in recent years.
To account for these differences, investigators compared characteristics of 8,864 patients in the trial to 568,540 contemporary patients with similar cardiovascular conditions. The scientists, who were led by first author Neel M. Butala, MD, MBA, and senior author Robert W. Yeh, MD, MSc, found that contemporary patients had more comorbidities and were more likely to have experienced a heart attack and to receive second-generation drug-eluting stents, which are coated with time-release medications and are more advanced than earlier stents. The team determined that differences between patients and stents used in contemporary clinical practice compared with the earlier clinical trial have translated into a decrease in benefits and an increase in harms attributable to prolonged use of antiplatelet drugs in recent years. Therefore, they say, it’s safer for today’s patients to take these medications for only a short amount of time after stent procedures.
“When we first published the study, we demonstrated that there was a clear benefit to taking a long duration of antiplatelet therapy for a large swath of patients undergoing heart stent procedures. But when we updated those results to incorporate the important changes that have occurred over the previous decade, much of the benefit of combination antiplatelet therapy had disappeared,” says Yeh, a physician-scientist at MGH and Beth Israel Deaconess Medical Center, who in addition to being the senior author of the Circulation analysis was a co-author of the original DAPT Study results published in NEJM .
Butala, an interventional cardiology fellow at MGH, notes that long-term antiplatelet therapy is no longer the best strategy for many, if not most, patients who have stents in their coronary arteries. “Instead, shorter regimens, sometimes as short as three or six months, may be a more typical duration to take these medications for the average cardiac patient,” he says.
Co-authors include Kamil F. Faridi, MD, MSc, Hector Tamez, MD, MPH, Jordan B. Strom, MD, MSc, Yang Song, MSc, Changyu Shen, PhD, Eric A. Secemsky, MD, MSc, Laura Mauri, MD, MSc, Dean J. Kereiakes, MD, Jeptha P. Curtis, MD, and C. Michael Gibson, MD, MS.
This work was supported by the National Heart, Lung, and Blood Institute and the American College of Cardiology’s National Cardiovascular Data Registry.
About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In August 2021, Mass General was named #5 in the U.S. News & World Report list of "America’s Best Hospitals."
Circulation
10.1161/CIRCULATIONAHA.121.056878
Observational study
People
Estimation of DAPT Study Treatment Effects in Contemporary Clinical Practice: Findings from the EXTEND-DAPT Study
8-Nov-2021
Dr. Butala reports consulting fees and ownership interest in HiLabs, outside the submitted work. Dr. Shen is an employee of Biogen, Inc. Dr. Secemsky receives grants from AstraZeneca, BD Bard, Boston Scientific, Cook Medical, CSI, Medtronic, Philips, and UCSF. He consults for BD Bard, CSI, Medtronic, and Philips and is on the speaking bureau of BD Bard, Cook Medical and Medtronic. Dr Mauri is an employee of Medtronic, Inc. Dr. Kereiakes has received consultant fees from SINO Medical Sciences Technologies, Inc., Boston Scientific Corporation, Svelte Medical Systems, Inc., Orchestra Biomed, Inc., Shockwave, Elixir Medical Corporation, and Abbott Vascular. Dr. Curtis receives salary support under contracts with the American College of Cardiology and CMS. Dr. Gibson reports grants and personal fees from Angel Medical Corporation, grants and personal fees from Bayer Corp., grants and personal fees from CSL Behring, grants and personal fees from Janssen Pharmaceuticals, grants and personal fees from Johnson & Johnson Corporation, personal fees from The Medicines Company, personal fees from Boston Clinical Research Institute, personal fees from Cardiovascular Research Foundation, personal fees from Eli Lilly and Company, personal fees from Gilead Sciences, Inc., personal fees from Novo Nordisk, personal fees from Web MD, personal fees from UpToDate in Cardiovascular Medicine, grants and personal fees from Portola Pharmaceuticals, personal fees from Amarin Pharma, personal fees from Amgen, personal fees from Boehringer Ingelheim , personal fees from Chiesi, personal fees from Merck & Co, Inc., personal fees from PharmaMar, personal fees from Sanofi, personal fees from Somahlution, personal fees from St. Francis Hospital, personal fees from Verreseon Corporation , personal fees from Boston Scientific, personal fees from Duke Clinical Research Institute, personal fees from Impact Bio, LTD, personal fees from MedImmune, personal fees from Medtelligence, personal fees from Microport, personal fees from PERT Consortium, other from nference, non-financial support from Baim Institute, grants from Bristol-Myers Squibb, grants from SCAD Alliance, personal fees from GE Healthcare, personal fees from Caladrius Bioscience, personal fees from CeleCor Therapeutics , personal fees from Thrombolytic Science , personal fees from AstraZeneca, personal fees from Eidos Therapeutics, personal fees from Kiniksa Pharmaceuticals. Dr. Yeh has research grants from Abbott Vascular, Abiomed, AstraZeneca, Cook, BD Bard, Boston Scientific, Medtronic, and Philips. Consulting: Abbott Vascular, AstraZeneca, Boston Scientific, and Medtronic. All other authors have nothing to disclose.