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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

Jeehoon Kang
1   Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
,
Kyung Woo Park
1   Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
,
Tullio Palmerini
2   Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
,
Gregg W. Stone
3   Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, United States
,
Michael S. Lee
4   Division of Cardiology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, United States
,
Antonio Colombo
5   San Raffaele Scientific Institute, Milan, Italy
,
Alaide Chieffo
5   San Raffaele Scientific Institute, Milan, Italy
,
Fausto Feres
6   Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
,
Alexandre Abizaid
6   Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
,
Deepak L. Bhatt
7   Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts, United States
,
Marco Valgimigli
8   Swiss Cardiovascular Center, Bern University Hospital, Bern University, Bern, Switzerland
,
Myeong-Ki Hong
9   Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
,
Yangsoo Jang
9   Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
,
Martine Gilard
10   Department of Cardiology, Brest University, Brest, France
,
Marie-Claude Morice
11   Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France
,
Duk-Woo Park
12   The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
,
Seung-Jung Park
12   The Heart Institute, University of Ulsan College of Medicine, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
,
Young-Hoon Jeong
13   Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
,
Jiesuck Park
1   Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
,
Bon-Kwon Koo
1   Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
,
Hyo-Soo Kim
1   Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Republic of Korea
› Author Affiliations Funding This study was supported by Korea Health Technology R&D grants funded by the Korea Government (Ministry of Health & Welfare; Grants HI-17 C-2085; and HI-14 C-1277) and by a grant (2320160100) from the Biomedical Institute, Seoul National University Hospital.
Further Information

Publication History

16 September 2018

25 October 2018

Publication Date:
31 December 2018 (online)

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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

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