Racial Differences in Ischaemia/Bleeding Risk Trade-Off during Anti-Platelet Therapy: Individual Patient Level Landmark Meta-Analysis from Seven RCTs

Jeehoon Kang; Kyung Woo Park; Tullio Palmerini; Gregg W. Stone; Michael S. Lee; Antonio Colombo; Alaide Chieffo; Fausto Feres; Alexandre Abizaid; Deepak L. Bhatt; Marco Valgimigli; Myeong-Ki Hong; Yangsoo Jang; Martine Gilard; Marie-Claude Morice; Duk-Woo Park; Seung-Jung Park; Young-Hoon Jeong; Jiesuck Park; Bon-Kwon Koo; Hyo-Soo Kim

doi:10.1055/s-0038-1676545

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2019; 119(01): 149-162
DOI: 10.1055/s-0038-1676545

Atherosclerosis and Ischaemic Disease

Georg Thieme Verlag KG Stuttgart · New York

Racial Differences in Ischaemia/Bleeding Risk Trade-Off during Anti-Platelet Therapy: Individual Patient Level Landmark Meta-Analysis from Seven RCTs

Authors

Jeehoon Kang

¹Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
Kyung Woo Park

¹Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
Tullio Palmerini

²Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
Gregg W. Stone

³Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, United States
Michael S. Lee

⁴Division of Cardiology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, United States
Antonio Colombo

⁵San Raffaele Scientific Institute, Milan, Italy
Alaide Chieffo

⁵San Raffaele Scientific Institute, Milan, Italy
Fausto Feres

⁶Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
Alexandre Abizaid

⁶Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
Deepak L. Bhatt

⁷Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, United States
Marco Valgimigli

⁸Swiss Cardiovascular Center, Bern University Hospital, Bern University, Bern, Switzerland
Myeong-Ki Hong

⁹Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
Yangsoo Jang

⁹Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
Martine Gilard

¹⁰Department of Cardiology, Brest University, Brest, France
Marie-Claude Morice

¹¹Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France
Duk-Woo Park

¹²The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
Seung-Jung Park

¹²The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
Young-Hoon Jeong

¹³Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
Jiesuck Park

¹Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
Bon-Kwon Koo

¹Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
Hyo-Soo Kim

¹Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea

Abstract

Background Prolonged dual anti-platelet therapy (DAPT) is intended to reduce ischaemic events, at the cost of an increased bleeding risk in patients undergoing percutaneous coronary intervention (PCI). In this study, we evaluated whether race influences the ischaemia/bleeding risk trade-off.

Methods We searched for randomized clinical trials (RCTs) comparing DAPT duration after PCI. To compare the benefit or harm between DAPT duration by race, individual patient-level landmark meta-analysis was performed after discontinuation of the shorter duration DAPT group in each RCT. The primary ischaemic endpoint was major adverse cardiac events (MACEs), and the primary bleeding endpoint was major bleeding events (clinicaltrials.gov NCT03338335).

Results Seven RCTs including 16,518 patients (8,605 East Asians, 7,913 non-East Asians) were pooled. MACE occurred more frequently in non-East Asians (0.8% vs. 1.8%, p < 0.001), while major bleeding events occurred more frequently in East Asians (0.6% vs. 0.3%, p = 0.001). In Cox proportional hazards model, prolonged DAPT significantly increased the risk of major bleeding in East Asians (hazard ratio [HR], 2.843, 95% confidence interval [CI], 1.474–5.152, p = 0.002), but not in non-East Asians (HR, 1.375, 95% CI, 0.523–3.616, p = 0.523). East Asians had a higher median probability risk ratio of bleeding to ischaemia (0.66 vs. 0.15), and the proportion of patients with higher probability of bleeding than ischaemia was significantly higher in East Asians (32.3% vs. 0.4%, p < 0.001).

Conclusion We suggest that the ischaemia/bleeding trade-off may be different between East Asians and non-East Asians. In East Asians, prolonged DAPT may have no effect in reducing the ischaemic risk, while significantly increases the bleeding risk.

Keywords

dual anti-platelet therapy - race - East Asians - ischaemia/bleeding trade-off

Full Text

References

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