In the Journals

Risk data support aggressive platelet inhibition 1 year after STEMI

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

In patients with STEMI, between 30 days and 1 year, daily risk for ischemia exceeded the daily risk for bleeding, according to new data from HORIZONS-AMI published in the Journal of the American College of Cardiology.

“The current findings support the use of potent platelet inhibition continuing through at least 1 year to prevent both primary and recurrent ischemic events, especially in patients without excessive bleeding risks,” Gennaro Giustino, MD, a resident at Icahn School of Medicine at Mount Sinai, and colleagues wrote.

Giustino and colleagues analyzed 3,602 patients with STEMI from the HORIZONS-AMI trial to determine average daily ischemic and bleeding rates after PCI; all received aspirin and clopidogrel for 1 year after PCI.

Ischemic events included cardiac death, reinfarction and definite stent thrombosis. Bleeding events included non-CABG-related TIMI major and minor bleeding. All events were categorized as acute (within 24 hours of PCI), subacute (between 1 and 30 days) and late (between 30 days and 1 year).

Risk declined over time

Between the acute and late periods, average daily ischemic rates and average daily bleeding rates decreased (P < .0001 for both), according to the researchers.

In the acute phase, there were no significant differences between the average daily ischemic rate and the average daily bleeding rate (least-squares mean difference, 0.11%; 95% CI, –0.35 to 0.58), Giustino and colleagues wrote.

According to the researchers, in the subacute phase, the average daily bleeding rate was greater than the average daily bleeding rate (least-squares mean difference, –0.39%; 95% CI, –0.58 to –0.2), but the reverse was true in the late phase (least-squares mean difference, 1.51%; 95% CI, 1.04-1.98).

“Given that, in the first 30 days, the overall burden of bleeding exceeded that of ischemia, bleeding avoidance strategies in this early high-risk period may be particularly effective in favorably shifting the benefit-to-risk equation,” Giustino and colleagues wrote. “In [the late] period, the absolute rate of ischemia was [approximately] 1.5-fold higher than the absolute rate of bleeding ... suggesting a particularly beneficial role in the late period for an agent to reduce ischemia further (as long as major bleeding is not markedly increased).”

Competing risks

In a related editorial, Derek P. Chew, MBBS, MPH, from the school of medicine at Flinders University of South Australia, Adelaide, and Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, wrote that “daily risks may differ substantially from those observed in clinical trials when therapies interact with competing risks arising from comorbidities.” – by Erik Swain

Disclosures: Giustino reports no relevant financial disclosures. Please see the full study for a list of the other authors’ relevant financial disclosures. Bhatt reports financial ties with numerous pharmaceutical and device companies. Chew reports he serves on the advisory board of Medscape Cardiology and receives speaker fees from AstraZeneca.

 

Deepak L. Bhatt, MD, MPH
Deepak L. Bhatt

In patients with STEMI, between 30 days and 1 year, daily risk for ischemia exceeded the daily risk for bleeding, according to new data from HORIZONS-AMI published in the Journal of the American College of Cardiology.

“The current findings support the use of potent platelet inhibition continuing through at least 1 year to prevent both primary and recurrent ischemic events, especially in patients without excessive bleeding risks,” Gennaro Giustino, MD, a resident at Icahn School of Medicine at Mount Sinai, and colleagues wrote.

Giustino and colleagues analyzed 3,602 patients with STEMI from the HORIZONS-AMI trial to determine average daily ischemic and bleeding rates after PCI; all received aspirin and clopidogrel for 1 year after PCI.

Ischemic events included cardiac death, reinfarction and definite stent thrombosis. Bleeding events included non-CABG-related TIMI major and minor bleeding. All events were categorized as acute (within 24 hours of PCI), subacute (between 1 and 30 days) and late (between 30 days and 1 year).

Risk declined over time

Between the acute and late periods, average daily ischemic rates and average daily bleeding rates decreased (P < .0001 for both), according to the researchers.

In the acute phase, there were no significant differences between the average daily ischemic rate and the average daily bleeding rate (least-squares mean difference, 0.11%; 95% CI, –0.35 to 0.58), Giustino and colleagues wrote.

According to the researchers, in the subacute phase, the average daily bleeding rate was greater than the average daily bleeding rate (least-squares mean difference, –0.39%; 95% CI, –0.58 to –0.2), but the reverse was true in the late phase (least-squares mean difference, 1.51%; 95% CI, 1.04-1.98).

“Given that, in the first 30 days, the overall burden of bleeding exceeded that of ischemia, bleeding avoidance strategies in this early high-risk period may be particularly effective in favorably shifting the benefit-to-risk equation,” Giustino and colleagues wrote. “In [the late] period, the absolute rate of ischemia was [approximately] 1.5-fold higher than the absolute rate of bleeding ... suggesting a particularly beneficial role in the late period for an agent to reduce ischemia further (as long as major bleeding is not markedly increased).”

Competing risks

In a related editorial, Derek P. Chew, MBBS, MPH, from the school of medicine at Flinders University of South Australia, Adelaide, and Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, wrote that “daily risks may differ substantially from those observed in clinical trials when therapies interact with competing risks arising from comorbidities.” – by Erik Swain

Disclosures: Giustino reports no relevant financial disclosures. Please see the full study for a list of the other authors’ relevant financial disclosures. Bhatt reports financial ties with numerous pharmaceutical and device companies. Chew reports he serves on the advisory board of Medscape Cardiology and receives speaker fees from AstraZeneca.

 

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