Rethinking dual antiplatelet guidelines in acute coronary syndrome? (CHANGE-DAPT)

August 29, 2017

Barcelona, Spain - 29 Aug 2017: New research presented at ESC Congress today1 suggests that for acute coronary syndrome (ACS) patients who require percutaneous coronary intervention (PCI), treatment according to contemporary guidelines for dual anti-platelet therapy (DAPT) could be less preferable than sticking to older guidelines.

Findings from the observational CHANGE-DAPT trial "represent another stone in a mosaic of recent studies and real-world registries that, taken as a whole, may stimulate a discussion about the optimal DAPT in ACS patients undergoing PCI," said senior investigator Dr Clemens von Birgelen, PhD, from Thoraxcentrum Twente in Enschede in The Netherlands.

"We were really surprised to see that by implementing current guidelines we saw no advantage over previous guidelines in terms of reducing ischemic events in our study population - but we did see an increase in major bleeding," he said.

International DAPT guidelines have gone through a change in the past five years, leaning towards more potent P2Y12- inhibitors such as prasugrel or ticagrelor rather than clopidogrel in ACS patients.

The change is based largely on results of the pivotal PLATO study, which assessed moderate-to-high risk ACS patients treated by pharmacotherapy alone or by coronary revascularization with PCI or bypass surgery.

But results from PLATO's PCI-treated patients may need updating in view of more recent data, suggested Dr. von Birgelen.

"One can understand that the use of ticagrelor resulted in an advantage at the time of that trial," he said, explaining that "most patients who underwent PCI in the PLATO study were treated with bare metal stents or older drug-eluting stents (DES)."

"But the contemporary newer-generation DES used in all of our CHANGE DAPT patients, have a much lower stent thrombosis risk than first-generation DES and a lower repeat revascularization risk than bare metal stents," he added. "And so, with contemporary DES, the risk-benefit balance of ticagrelor appears to have shifted in ACS patients undergoing PCI. Adverse events with PCI are significantly lower, making major side effects and complications from DAPT increasingly relevant."

CHANGE-DAPT examined the impact of the guideline change at one-year follow-up in a consecutive series of 2,062 ACS patients not on oral anticoagulation therapy who were treated by PCI with newer-generation DES at Thoraxcentrum Twente in the Netherlands.

Compared to 1,009 patients treated with clopidogrel (before the change), the 1,053 patients treated with ticagrelor after the change had a significantly higher risk for the composite outcome of all-cause death, any myocardial infarction, stroke, or major bleeding (5.1% vs.7.8%; p=0.02). The incidence of major bleeding alone was also higher after the change (1.2% vs. 2.7%, p=0.02).

"These findings in PCI-treated ACS patients should not be generalized to other patient groups - that is non-ACS patients, or ACS patients treated with primary bypass surgery or without revascularization," said to Dr. von Birgelen.

However, considering results from the TOPIC trial (EHJ, 2017), and data from the SCAAR registry (reported in May 2017 at the EuroPCR meeting),"there is a need for a scientific discussion about optimal DAPT in ACS patients who require PCI," he concluded.

European Society of Cardiology

Related Ticagrelor Articles from Brightsurf:

Clinical trial shows potential benefit to anti-platelet therapy
Heart patients who undergo percutaneous coronary intervention (PCI) or stent placement? nonsurgical procedures to improve blood flow to the heart are typically prescribed anti-platelet therapy to avoid blood clots that can lead to a heart attack or stroke.

Cardiology trial shows potential benefit of genetic testing when selecting blood thinners
An international, first-of-its-kind cardiology trial used personalized genetic testing to reduce by 34 per cent the number of serious adverse events following balloon angioplasty, a treatment for the most common form of heart disease.

Safety of bioabsorbable polymer against durable polymer DES in high-risk PCI patients
A novel study sought to reveal whether drug-eluting stents (DES) coated with bioabsorbable polymer (BP) presented a safety advantage without compromising efficacy compared to durable polymer (DP) formulations.

Precision medicine guides choice of better drug therapy in severe heart disease
Is personalized medicine cost-effective? Researchers have answered that question for one medical treatment, genotype-guided antiplatelet therapy for acute coronary syndrome patients with PCI.

Benefit seen for ticagrelor alone, without aspirin, in patients with ACS
The research was presented at the American College of Cardiology's Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC).

Ticagrelor alone, without aspirin, shows benefit in patients with diabetes
Patients with diabetes who stopped taking aspirin three months after the insertion of a coronary stent and then took the anti-platelet medication ticagrelor alone for a year had fewer episodes of bleeding and no increase in heart attacks, stroke or other adverse events caused by blockages in the arteries, compared with patients who took both aspirin and ticagrelor for a year.

Dropping aspirin for ticagrelor alone better in complex heart disease
The research, a subanalysis of the TWILIGHT trial, was presented at the American College of Cardiology's Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC).

Genetic testing for antiplatelet therapy post-PCI misses cut in cardiovascular events
An international clinical trial that used genetic testing to guide which antiplatelet medication was given to patients following percutaneous coronary intervention (PCI) did not meet its stated goal for cutting in half the incidence of serious adverse cardiovascular events, such as heart attack and stroke, in the year following the procedure, according to study results presented at the American College of Cardiology's Annual Scientific Session Together with World Congress of Cardiology (ACC.20/WCC).

Additional heart artery stenting reduces risk of future heart attacks
Research has shown that patients who have had emergency heart attack treatment with heart artery stenting -- and have significant narrowings in their other untreated arteries -- can benefit from additional stenting to help prevent future heart attacks.

The Lancet journals: Papers at ESC Congress 2019
The following papers will be presented at the ESC Congress 2019, organised by the European Society of Cardiology in Paris and published simultaneously in either The Lancet or The Lancet Global Health journals.

Read More: Ticagrelor News and Ticagrelor Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to