The following is a summary of “P2Y12 Inhibitor Monotherapy or Dual Antiplatelet Therapy After Complex Percutaneous Coronary Interventions,” published in the February 2023 issue of Cardiology by Gragnano, et al.

Compared to dual antiplatelet treatment (DAPT) after complex percutaneous coronary intervention (PCI), the effectiveness of P2Y12 inhibitor monotherapy in maintaining ischemia protection while reducing bleeding risk was yet unknown. With regard to PCI complexity, researchers compared the effects of P2Y12 inhibitor monotherapy given after a 1- to 3-month DAPT to those of normal DAPT.

They aggregated patient-level data from randomized controlled trials to compare the effects of standard DAPT and P2Y12 inhibitor monotherapy on outcomes that were centrally judged following coronary revascularization. Any one of the following six criteria was used to identify complex PCI: 3 vessels treated, ≥3 lesions treated, ≥3 stents inserted, bifurcation with two stents implanted, total stent length >60 mm, or complete chronic occlusion. All-cause mortality, myocardial infarction, and stroke were the main efficacy endpoints. The main safety objective was blood loss of Bleeding Academic Research Consortium (BARC) 3 or 5.

4,685 (20.4%) of the 22,941 participants in 5 studies who underwent PCI showed greater rates of ischemic events than those who received less sophisticated PCI. Patients with complex PCI (HR: 0.87; 95% CI: 0.64-1.19; P_interaction = 0.770) and noncomplex PCI (HR: 0.91; 95% CI: 0.76-1.09; P_interaction = 0.770) had similar primary efficacy outcomes with P2Y₁₂ inhibitor monotherapy and DAPT. All elements of the complex PCI definition’s treatment impact were uniform. P2Y₁₂ inhibitor monotherapy consistently decreased BARC 3 or 5 bleeding in complicated PCI patients (HR: 0.51; 95% CI: 0.31-0.84; P_interaction = 0.920) and noncomplex PCI patients (HR: 0.49; 95% CI: 0.37-0.64; P_interaction= 0.920) when compared to DAPT.

Regardless of PCI complexity, P2Y12 inhibitor monotherapy following 1- to 3-month DAPT was linked to decreased major bleeding risk and similar rates of fatal and ischemic events compared to normal DAPT.

Reference: jacc.org/doi/10.1016/j.jacc.2022.11.041