Peter Ueda1, Tomas Jernberg2, Stefan James3, Joakim Alfredsson4, David Erlinge5, Elmir Omerovic6, Jonas Persson2, Annica Ravn-Fischer7, Per Tornvall8, Bodil Svennblad9, Christoph Varenhorst10. 1. Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden. Electronic address: peter.ueda@ki.se. 2. Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden. 3. Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden. 4. Department of Cardiology, Linköping University, Linköping, Sweden; Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden. 5. Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden. 6. Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden. 7. Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden. 8. Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. 9. Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden. 10. Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Pfizer AB, Sollentuna, Sweden.
Abstract
BACKGROUND: The dual antiplatelet therapy (DAPT) score guides decisions on DAPT duration after coronary stenting by simultaneously predicting ischemic and bleeding risk. OBJECTIVES: This study sought to assess the performance of the DAPT score in a nationwide real-world population. METHODS: The study used register data in Sweden (2006 to 2014) and followed 41,101 patients who had undergone 12 months of event-free DAPT, from months 12 to 30 after stenting. Risk of myocardial infarction (MI) or stent thrombosis, major adverse cardiovascular and cerebrovascular events (MACCE) (MI, stroke, and all-cause death), and fatal or major bleeding were compared according to DAPT score. RESULTS: The score had a discrimination of 0.58 (95% confidence interval [CI]: 0.56 to 0.60) for MI or stent thrombosis, 0.54 (95% CI: 0.53 to 0.55) for MACCE, and 0.49 (95% CI: 0.45 to 0.53) for fatal or major bleeding. Risk of MI or stent thrombosis was significantly increased at scores of ≥3 while MACCE risk followed a J-shaped pattern and increased at scores of ≥4. Absolute differences in fatal or major bleeding risk were small between scores. Event rates of ischemic and bleeding outcomes in patients with high (≥2) and low (<2) scores differed compared to the DAPT Study from which the score was derived; fatal or major bleeding rates were approximately one-half of those in the placebo arm of the DAPT Study. CONCLUSIONS: In a nationwide population, the DAPT score did not adequately discriminate ischemic and bleeding risk, the relationship between score and ischemic risk did not correspond to the suggested decision rule for extended DAPT, and risk of bleeding was lower compared with the DAPT Study. The score and its decision rule may not be generalizable to real-world populations.
BACKGROUND: The dual antiplatelet therapy (DAPT) score guides decisions on DAPT duration after coronary stenting by simultaneously predicting ischemic and bleeding risk. OBJECTIVES: This study sought to assess the performance of the DAPT score in a nationwide real-world population. METHODS: The study used register data in Sweden (2006 to 2014) and followed 41,101 patients who had undergone 12 months of event-free DAPT, from months 12 to 30 after stenting. Risk of myocardial infarction (MI) or stent thrombosis, major adverse cardiovascular and cerebrovascular events (MACCE) (MI, stroke, and all-cause death), and fatal or major bleeding were compared according to DAPT score. RESULTS: The score had a discrimination of 0.58 (95% confidence interval [CI]: 0.56 to 0.60) for MI or stent thrombosis, 0.54 (95% CI: 0.53 to 0.55) for MACCE, and 0.49 (95% CI: 0.45 to 0.53) for fatal or major bleeding. Risk of MI or stent thrombosis was significantly increased at scores of ≥3 while MACCE risk followed a J-shaped pattern and increased at scores of ≥4. Absolute differences in fatal or major bleeding risk were small between scores. Event rates of ischemic and bleeding outcomes in patients with high (≥2) and low (<2) scores differed compared to the DAPT Study from which the score was derived; fatal or major bleeding rates were approximately one-half of those in the placebo arm of the DAPT Study. CONCLUSIONS: In a nationwide population, the DAPT score did not adequately discriminate ischemic and bleeding risk, the relationship between score and ischemic risk did not correspond to the suggested decision rule for extended DAPT, and risk of bleeding was lower compared with the DAPT Study. The score and its decision rule may not be generalizable to real-world populations.
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