Appraising the counter-balancing ischemia and bleeding risks for dual antiplatelet therapy duration after coronary stenting

Complex percutaneous coronary intervention (PCI) is associated with higher risk of ischemic complications. Long-term dual antiplatelet therapy (DAPT) could be useful to reduce this risk. However, the presence of concomitant high bleeding risk (HBR) make unclear the optimal balance between ischemic and bleeding risk for DAPT duration. We evaluated the impact of DAPT duration based on the baseline ischemic and bleeding risks after coronary stenting. Ischemic risk was based on a complex PCI definition:≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Bleeding risk was evaluated based on the PRECISE-DAPT score with high (≥25) or non-high (<25) score. Bleeding events were accounted according to the Thrombolysis In Myocardial Infarction scale. Patients were assigned randomized DAPT duration for 3/6 months or 12/24 months. A total of 14,963 patients from 8 randomized trials have been inclued, with 3,118 underwent complex PCI. Complex PCI patients experienced a higher rate of ischemic, but not an increased risk of bleeding events. Long-term DAPT reduced ischemic risk in non-HBR patients in both patients with complex PCI (ARD: −3.86%; 95%CI: −7.71 to +0.06) and without complex PCI (ARD: −1.14%; 95%CI: −2.26 to −0.02). Yet, among HBR patients no benefit of longer DAPT was observed, irrespective of PCI complexity. Long-term DAPT increased bleeding only in HBR patients, irrespective of PCI complexity. Complex PCI patients carry a higher risk of ischemic events, but received a benefit from long-term DAPT only if not at concomitant HBR. For this reason, when concordant, bleeding risk, more than ischemic risk, should be prioritized to inform decision-making on the duration of DAPT.