Temporal Modulation of Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention for Highly Complex Anatomy: A Post-hoc Analysis of the TAILORED-CHIP Trial

초록

BACKGROUND The optimal antiplatelet strategy for patients undergoing percutaneous coronary intervention (PCI) for very high-risk coronary anatomy remains uncertain. We evaluated the efficacy and safety of a tailored, time-modulated antiplatelet regimen in this patient population. METHODS This was a prespecified subgroup analysis of the TAILORED-CHIP trial, including patients with highly complex coronary anatomy (unprotected left main disease, two-stent bifurcation techniques, chronic total occlusion, or PCI requiring 3 planned stents, >3 lesions treated, or expected total stent length >60 mm). A tailored antiplatelet therapy with early escalation (low-dose ticagrelor 60 mg twice daily plus aspirin for <6 months) followed by late de-escalation (clopidogrel monotherapy for 6 months) was compared with conventional dual antiplatelet therapy (clopidogrel plus aspirin for 12 months). The primary outcome was a composite of death from any cause, myocardial infarction, stroke, stent thrombosis, unplanned urgent revascularization, and clinically relevant bleeding (Bleeding Academic Research Consortium type 2, 3, or 5) at 12 months. RESULTS Among 2,018 randomized patients, 1,309 (64.9%) underwent PCI for highly complex coronary artery lesions; 627 (47.9%) received tailored antiplatelet therapy and 682 (52.1%) conventional dual antiplatelet therapy. At 12 months, a primary outcome event occurred in 71 patients (11.3%) in the tailored antiplatelet therapy group and in 76 patients (11.1%) in the conventional therapy group (hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.74–1.42; P=0.86). The incidence of major ischemic events was lower with tailored therapy (3.7% vs. 6.5%, HR, 0.57; 95% CI, 0.34–0.94; P=0.03), while the incidence of clinically relevant bleeding was not significantly different between the two groups (8.1% vs. 6.0%, HR 1.40; 95% CI, 0.93–2.12; P=0.11). CONCLUSIONS In patients undergoing PCI for highly complex coronary anatomy, a tailored antiplatelet therapy did not reduce the primary net adverse events at 12 months compared to conventional therapy. Nevertheless, this approach was associated with a significant reduction in major ischemic events.