Professor Roxana Mehran: How to optimize the duration of DAPT after PCI and how to reduce the treatment order?

Editor's note: Anti-platelet therapy, as the cornerstone of post-operative treatment of percutaneous coronary intervention (PCI), is of great value in reducing the risk of postoperative thrombosis and improving the prognosis. With the deepening of research and improvement of stent technology, the antithrombotic treatment scheme after percutaneous coronary intervention is becoming more and more personalized. At this CIT 2021 Conference, Professor Roxana Mehran from Mount Sinai Hospital in New York, USA was invited by us to have an in-depth interview on issues such as "Optimizing the Duration of Double Anti-Platelet Therapy (DAPT) after PCI and How to Reduce the Treatment Order". 

《International Circulation》: Antithrombotic therapy after PCI has always been the focus of attention. As a reviewer of the paper, would you please share us the latest research progress in this field?

Professor Roxana Mehran: Antithrombotic therapies are the cornerstone of our treatment of patients after stenting, PCI, etc. And over the years, they have really evolved as we begin to think about the differences in how different patients have different outcomes with different durations, etc., of antithrombotic regimens. And while you might prescribe or recommend a certain length of treatment with dual antiplatelet therapies, not one size fits all.

So over the years, when we’ve stopped dual platelet therapies, we’ve always reverted to aspirin. And I think that these last few years, we're now evolving into, perhaps, a novel approach of dropping aspirin and staying with a P2Y12 inhibitor monotherapy. And that is sort of a new evolving regimen that seems to be effective. It still has good outcomes in terms of minimizing eschemic complications and as well as reducing bleeding. So, there is no ischemic harm and there is a huge bleeding benefit with going to a P2Y12 monotherapy.

It is also important to note that the reason why I think we're able to do this and shorten the duration, deescalate, or go to a single antiplatelet regimen with a P2Y12 monotherapy—all of it—is because of the incredible stent technology improvement, improvement in PCI techniques, as well as use of physiology and imaging. All of these things have improved our ischemic outcome so now we can manage antiplatelet therapies better.

《International Circulation》: Your team has also conducted research on antithrombosis after PCI. What are the results it has achieved so far? What is the next research direction?

Professor Roxana Mehran: we felt it was important to address the question of a P2Y12 monotherapy, compared to dual antiplatelet therapy in high risk patients. In patients in home we would be giving a potent P2Y12 inhibitor like ticagrelor.  And can we minimize that bleeding issue that we are seeing, and keeping the patients on a longer duration of a potent P2Y12 inhibition by having a dropping of the aspirin.

And so, we designed the TWILIGHT trial in a double blind placebo controlled fashion. We randomized 7,119 patients. We had a wonderful result with a massive increase in bleeding complications with no issue about ischemic events. We were able to accomplish this with our colleagues from China. We had a wonderful engagement of Chinese sites and we were able to work together. And we're most thankful for the wonderful collaboration we had with Professor Han Ya-Ling. And we were able to perform this. Our next goal now is to see if we can drop the aspirin sooner than 3 months. And we are designing larger randomized trials in that way, looking at different regimens.

《International Circulation》: DAPT is the standard regimen of antithrombotic therapy for PCI patients, and its treatment duration has always been controversial. In your opinion, what are the main factors that determine the duration of DAPT?

Professor Roxana Mehran: I think that's a really good question. The duration of dual antiplatelet therapy has not yet been optimized. There is no one size fits all, as I said before. And it has to be individualized to the patient's risk. And so, there is that understanding that if we use the patients’ demographics and understand what's their risk profile, understand the burden of atherosclerosis, and, especially, if they have peripheral arterial disease, extra cardiac manifestations of atherosclerosis—I think those patients are at high risk and you really want to keep them for as long as possible especially on a P2Y12 inhibitor.

And I think that with patients who are at high bleeding risk, we really want to de-escalate and shorten the duration of that. And we have the ARC-HBR criteria that really helps you evaluate who those patients are. And I think that's a very, very good way of using that kind of patient profile to be able to mitigate risks and improve outcomes of our patients. Balancing ischemic and bleeding events are crucial in choosing a regimen of DAPT in pts.  We must take into account the burden of CAD/PAD, in all pts, and understand the risk of bleeding in our elederly more frail population.  Balancing this, without causing ischemic harm is the most important quest for achieving best outcomes for pts undergoing PCI.