DES Thrombosis Restenosis DAPT Duration DES Thrombosis No

DES Thrombosis, Restenosis & DAPT Duration DES Thrombosis No Longer an Issue with Second Generation DES William Wijns MD Ph. D NUI Galway, Ireland Thomas Cuisset MD Marseille, France

William Wijns, MD Ph. D Relations of Interest Disclosures Institutional Research Grants: MICell Technologies, Micro. Port, St Jude- Abbott, Terumo Advisory Board & honoraria: Micro. Port Shareholder & non executive Board member: Argonauts, Genae

DAPT = Gold standard after ACS and DES 1 m 3 m 6 m 12 m 30 m SHORT LONG Thrombotic risk Bleeding Risk Stent thrombosis Recurrent ACS Bleeding events

Improvement of DES technology Thinner strut Biodegradable polymer Abluminal polymer Drug and polymer release → Lower risk of ST ? → Shorter DAPT possible ? Stefanini, Taniwaki, Windecker. Heart 2013

n % ACS Ischemic Bleeding DES LATE, NEJM 2010 2117 60% 12 Mo = >12 Mo No difference EXCELLENT, JACC 2012 1443 50% 6 Mo = 12 Mo No Difference PRODIGY, Circulation 2012 2013 75% 6 Mo = 24 Mo More bleeding RESET, JACC 2012 2117 55% 3 Mo = 12 Mo No difference OPTIMIZE, JAMA 2013 3119 30% 3 Mo = 12 Mo More bleeding ARCTIC, Lancet 2014 1259 25% 12 Mo = >12 Mo More Bleeding SECURITY, JACC 2014 1399 40% 6 Mo = 12 Mo No difference ISAR SAFE, EHJ 2015 4005 40% 6 Mo = 12 Mo More Bleeding ITALIC, JACC 2014 2031 25% 6 Mo = 24 Mo No difference OPTIDUAL, JACC 2015 1385 35% 12 Mo = 48 Mo No DIfference “Short DAPT” as effective with less bleedings

Short vs Long DAPT: Choice? Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Long DAPT

Short vs Long DAPT: Choice with the patient Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Long DAPT

Short vs Long DAPT: Choice with the PCI Elderly patient High Bleeding risk Patient with OAC ‘Simple’ PCI, single VD Stable CAD Non Diabetic New generation DES Short DAPT Young patient Low Bleeding risk Multivessel disease Complex PCI Prior Stent thrombosis STEMI Diabetic First generation DES BRS Long DAPT

Optical coherence tomography-near-infrared fluorescence (OCT-NIRF) imaging for the assessment of drug-eluting stent-associated coronary inflammation Sunwon Kim et al. Eur Heart J 2016; eurheartj. ehv 726 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals. permissions@oup. com.

Impact of PCI Complexity on long-term DAPT benefit Factors of Complex PCI 3 Vessel PCI Bifurcation w/ 2 DES ≥ 3 DES Total DES lenth > 60 mm CTO → 17. 5% of patients 9577 patients from DAPT duration studies > 12 Mo vs 3 -6 Mo DAPT Giustino et al, JACC 2016

PEGASUS study -1. 2% +1. 2% 60 mg + 1. 5% 90 mg Bonaca et al, NEJM 2015

Choice of DAPT duration: Rule and exceptions ! After DES Improvement of DES technology Evidence that shorter DAPT is safe in low-risk patients with new DES 6 Mo as rule, shorter in high bleeding risk patients (1 -3) Longer in very selected patients After ACS 12 Mo as rule, shorter in high bleeding risk patients (1 -3 -6) Evidence that high-risk ACS pts benefit from longer DAPT (CHARISMA post-MI, DAPT post-MI, PEGASUS)

DAPT duration DAPT indication For the patient ? Optimal Duration For DES ? Minimal Duration ? Prevention of recurrent events Prevention of stent thrombosis