Korean Circ J.  2024 Apr;54(4):189-200. 10.4070/kcj.2023.0268.

The Association of CHADS-P2A2RC Risk Score With Clinical Outcomes in Patients Taking P2Y12 Inhibitor Monotherapy After 3 Months of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention

• Song PS
• Seong SW
• Kim JY
• An SY
• Kim MJ
• Ahn KT
• Jin SA
• Jeong JO
• Yang JH
• Hahn JY
• Gwon HC
• Jang WJ
• Yoon HJ
• Bae JW
• Choi WG
• Song YB

• KMID: 2555531
• DOI: http://doi.org/10.4070/kcj.2023.0268

Abstract

Background and Objectives
Concerns remain that early aspirin cessation may be associated with potential harm in subsets at high risk of ischemic events. This study aimed to assess the effects of P2Y12 inhibitor monotherapy after 3-month dual antiplatelet therapy (DAPT) vs. prolonged DAPT (12-month or longer) based on the ischemic risk stratification, the CHADSP2A2RC, after percutaneous coronary intervention (PCI).
Methods
This was a sub-study of the SMART-CHOICE trial. The effect of the randomized antiplatelet strategies was assessed across 3 CHADS-P2A2RC risk score categories. The primary outcome was a major adverse cardiac and cerebral event (MACCE), a composite of all-cause death, myocardial infarction, or stroke.
Results
Up to 3 years, the high CHADS-P2A2RC risk score group had the highest incidence of MACCE (105 [12.1%], adjusted hazard ratio [HR], 2.927; 95% confidence interval [CI], 1.358–6.309; p=0.006) followed by moderate-risk (40 [1.4%], adjusted HR, 1.786; 95% CI, 0.868–3.674; p=0.115) and low-risk (9 [0.5%], reference). In secondary analyses, P2Y12 inhibitor monotherapy reduced the Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding without increasing the risk of MACCE as compared with prolonged DAPT across the 3 CHADS-P2A2RC risk strata without significant interaction term (interaction p for MACCE=0.705 and interaction p for BARC types 2, 3, or 5 bleeding=0.055).
Conclusions
The CHADS-P2A2RC risk score is valuable in discriminating high-ischemicrisk patients. Even in such patients with a high risk of ischemic events, P2Y12 inhibitor monotherapy was associated with a lower incidence of bleeding without increased risk of ischemic events compared with prolonged DAPT.

Keyword

Coronary artery disease; Angioplasty; Dual anti-platelet therapy; Prognosis

Figure

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  Figure 1 Kaplan-Meier survival curves with Log-rank test of the (A) MACCE, (B) all-cause death, (C) MI, (D) stroke, (E) BARC types 2, 3, or 5, and (F) BARC types 3 or 5. MACCE was defined as a composite of all-cause death, MI, and stroke.BARC = Bleeding Academic Research Consortium; MACCE = major adverse cardiac cerebral event; MI = myocardial infarction.

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  Figure 2 Risk stratification strategies to guide antiplatelet therapy by the CHADS-P2A2RC risk criteria. MACCE was defined as a composite of all-cause death, recurrent myocardial infarction, and stroke.CI = confidence interval; DAPT = dual antiplatelet therapy; HR = hazard ratio; MACCE = major adverse cardiac cerebral event.

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