| Background and ObjectivesAcute ST-segment elevation myocardial infarction(STEMI)is a serious type of CVDs,and its morbidity and mortality are still increasing rapidly in China.Percutaneous coronary intervention(PCI)is the most effective step to achieve timely reperfusion in STEMI patients,and dual antiplatelet therapy(DAPT)is the cornerstone of preventing recurrent cardiac and systemic ischemic events in STEMI patients after PCI.However,the majority of patients do not pay enough attention to DAPT,and irregular medication use after discharge is widespread.Moreover,it remains controversial whether the premature cessation of DAPT in patients leads to an increased risk of subsequent cardiac ischemia.Our study aimed to explore the incidence,causes of cessation,influencing factors,and prognostic analysis of premature DAPT cessation after PCI in STEMI patients,and to provide data for an in-depth discussion of the optimal duration of DAPT after PCI in STEMI patients.Materials and MethodsThis study relied on a multicenter,prospective STEMI cohort constructed by the Evaluation of Antithrombotic Strategies in STEMI patients in China(EAST-STEMI)study.The study selected a cohort of STEMI patients undergoing PCI between 2018 and 2020,and divided them into a no DAPT cessation group and a premature DAPT cessation group based on whether DAPT was ceased within 1 year after PCI,as well as the premature DAPT cessation group was further divided into two groups for analysis according to whether the duration of DAPT was 6 months.The primary endpoint of this analysis was the occurrence of major adverse cardiovascular and cerebrovascular events(MACCE)-a composite of cardiac death,recurrent myocardial infarction,unplanned coronary revascularization,definite or probable stent thrombosis,or ischemic stroke.The secondary endpoints were the risk of bleeding events,including major bleeding(Bleeding Academic Research Consortium[BARC]type 3,5)and minor bleeding(BARC type 2).The Cox proportional hazards model was used to explore the influencing factors of premature DAPT cessation and to estimate the hazard ratio(HR)and 95%confidence interval(CI)of premature DAPT cessation on the primary and secondary outcomes.The Log-Rank method was used to compare the differences in the risk of adverse events between groups.The relationship between premature cessation of DAPT and age in STEMI patients is described by the restrictive cubic spline(RCS).A two-sided test was used for statistical results,and difference was indicated as statistically significant at P<0.05.Results1.A total of 6,594 patients with STEMI undergoing PCI were enrolled in this study,6,040 in the no DAPT cessation group and 554 in the premature DAPT cessation group.Compared with the no DAPT cessation group,patients in the premature DAPT cessation group were significantly older(64.05± 11.60 vs.61.48± 11.78;P<0.001)and received a higher proportion of femoral artery approach during PCI(10.65%vs.7.43%;P=0.007).There was no statistical difference between the two groups in the remaining variables(P>0.05).2.This study found that 8.40%of STEMI patients had premature cessation of DAPT within 1 year after PCI.Among these patients,66.06%of patients who ceased DAPT did so on physician recommendation and 33.94%did so on their own.Among patients whose physician recommended the cessation of DAPT,bleeding was the most important reason(60.11%).Among patients who ceased DAPT on their own,poor patient compliance was the most important reason(35.11%).3.A multivariate Cox regression analysis showed that age(HR:1.20;95%CI:1.11-1.30;P<0.001)and femoral approach during PCI(HR:1.41;95%CI:1.07-1.84;P=0.014)were independent risk factors for premature cessation of DAPT in patients with STEMI.A linear relationship between the risk of premature DAPT cessation and age overall was found by RCS,with the likelihood of premature cessation occurring with increasing age.4.This study found a reduced risk of MACCE(3.61%vs.5.84%;HR:0.55;95%CI:0.35-0.86;P=0.009)and cardiac death(0.90%vs.1.75%;HR:0.40;95%CI:0.16-0.99;P=0.048)in the premature DAPT cessation group compared with the no DAPT cessation group,and an increased risk of major bleeding(1.26%vs.0.33%;HR:3.49;95%CI:1.44-8.49;P=0.006)and minor bleeding(11.91%vs.8.69%;HR:1.36;95%CI:1.05-1.76;P=0.018).5.The analysis was performed according to the duration of DAPT after PCI in STEMI patients,and the premature DAPT cessation group was divided into two groups of ≤6 months and 6-12 months.The results showed that compared with the no DAPT cessation group,there was no statistical difference in the risk of MACCE in patients with DAPT duration within 6 months,and there was a significantly increased risk of major bleeding(1.97%vs.0.33%;HR:4.74;95%CI:1.81-12.37;P=0.001)and minor bleeding(16.07%vs.8.69%;HR:1.89;95%CI:1.41-2.53;P<0.001).In contrast,the risk of MACCE(2.01%vs.5.84%;HR:0.33;95%CI:0.13-0.79;P=0.013)was significantly lower in patients with DAPT duration of 6-12 months,and for bleeding events,no significant difference was found between the two groups(P>0.05).6.To adequately elaborate on the results of the prognostic analysis,we performed a subgroup analysis according to the reasons for the cessation of DAPT in patients.First,subgroup analysis based on whether the reason for cessation was physician-advised found that for patients who ceased DAPT on physician recommendation,the risk of MACCE(HR:0.21;95%CI:0.05-0.86;P=0.029)was significantly lower for patients with a DAPT duration of 6-12 months,and no significant difference in the risk of bleeding events was observed.For patients who ceased DAPT on their own,no significant difference in MACCE and bleeding events was observed between the groups.Second,subgroup analysis based on whether the reason for cessation was due to bleeding found that for patients who ceased DAPT for non-bleeding reasons,the risk of MACCE(HR:0.30;95%CI:0.10-0.95;P=0.040)was significantly lower in patients with a DAPT duration of 6-12 months and no significant risk of bleeding events was observed(HR:0.44;95%CI:0.20-0.98;P=0.045).Conclusions1.The incidence of premature DAPT cessation in STEMI patients within 1 year after PCI was 8.40%.Age and femoral approach during PCI were independent risk factors for premature cessation of DAPT in STEMI patients.2.Patients with STEMI taking DAPT for 6-12 months after PCI showed a favorable efficacy and safety profile,significantly reducing the risk of ischemia and not increasing the risk of bleeding.However,DAPT should be ceased on the advice of the physician and the adverse consequences of arbitrary cessation should be avoided. |
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