Tailoring Antithrombotic Regimens for Percutaneous Coronary Intervention Patients with High Bleeding and Ischemic Risk (TAILOR-BIRISK): Individualized Management and Genotype-Guided De-escalation

Tailoring Antithrombotic Regimens for Percutaneous Coronary Intervention Patients with High Bleeding and Ischemic Risk (TAILOR-BIRISK): Individualized Management and Genotype-Guided De-escalation

Junyan Zhang^1,†, Zhongxiu Chen^1,†, Yong He^1,*

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¹ Department of Cardiology, West China Hospital of Sichuan University, 610041 Chengdu, Sichuan, China

^*Correspondence: heyongmd@wchscu.cn (Yong He)
^†These authors contributed equally.

Rev. Cardiovasc. Med. 2023, 24(12), 348; https://doi.org/10.31083/j.rcm2412348

Submitted: 2 June 2023 | Revised: 6 July 2023 | Accepted: 11 July 2023 | Published: 12 December 2023

This is an open access article under the CC BY 4.0 license.

Abstract

Percutaneous coronary intervention (PCI) is a widely used reperfusion strategy for coronary artery disease, with millions of procedures performed annually. Attention has recently been drawn to a unique population, known as “bi-risk” patients, who have high ischemic and high bleeding risks and undergo PCI. However, there is currently no established definition or optimal antithrombotic therapy for this group. Genotype-guided antithrombotic therapy, which uses cytochrome P450 (CYP) 2C19 gene testing, may offer a more personalized and precise approach. Nevertheless, recent research has shown that routine genetic testing to guide treatment in the PCI population does not improve patient outcomes, preventing it from being routinely recommended in guidelines. This review proposes, for the first time, the definition of the bi-risk population and the concept of TAILOR-BIRISK for their treatment strategies. TAILOR-BIRISK emphasizes de-escalating antithrombotic treatment and suggests that a short course of dual antiplatelet therapy (DAPT) followed by monotherapy by either clopidogrel or ticagrelor 60 mg BID (BID, twice daily) could be a reasonable option for this population. Additionally, the use of CYP2C19 gene testing to guide P2Y ${}_{\text{12}}$ inhibitor selection can help better individualize and customize the antithrombotic regimen. However, more large-sample randomized control studies should be conducted to further explore the optimal antithrombotic strategy for the bi-risk population.

Keywords

percutaneous coronary intervention

high bleeding risk

high ischemic risk

genotype-guided

CYP2C19

Funding

82100282/Natural Science Foundation of China

2021HXFH021/1.3.5 project for disciplines of excellence–Clinical Research Incubation Project

2022YFS0357/The Science & Technology Pillar Program of Sichuan Province

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Fig. 1.

Characteristics of patients undergoing PCI with high bleeding and ischemia risk and the concept of TAILOR-BIRISK. The concept indicates de-escalating antithrombotic treatment and suggests that short-term dual antiplatelet therapy combined with clopidogrel monotherapy or ticagrelor 60 mg BID monotherapy in maintenance is feasible for this bi-risk population. The use of CYP2C19 gene testing to guide P2Y ${}_{\text{12}}$ inhibitor selection can help better individualize and customize the antithrombotic regimen. STEMI, ST segment elevation myocardial infarction; CTO, chronic total occlusion; CKD, chronic kidney disease; NSAIDs, nonsteroidal anti-inflammatory drugs; CYP2C19, cytochrome P450 2C19; ST, stent thrombosis; DAPT, dual antiplatelet therapy; SMART-DATE, smart angioplasty research team-safety of 6-month duration of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome; REDUCE, short-term dual anti platelet therapy in patients with ACS treated with the COMBO dual-therapy stent; TICO, ticagrelor monotherapy after 3 months in the patients treated with new generation sirolimus stent for acute coronary syndrome; STOPDAPT-2, the short and optimal duration of dual antiplatelet therapy after everolimus-eluting cobalt-chromium stent; ACS, acute coronary syndrome; MASTER DAPT, management of high bleeding risk patients post bioresorbable polymer coated stent implantation with an abbreviated versus prolonged DAPT regimen; HBR, high bleeding risk; EVOLVE, a prospective, multicenter, single-arm study designed to assess the safety of 3-month DAPT in subjects at high risk for bleeding undergoing PCI with the SYNERGY everolimus-eluting platinum chromium coronary stent system; TWILIGHT, ticagrelor with aspirin or alone in high-risk patients after coronary intervention unfractionated heparin; I LOVE IT 2, evaluate safety and effectiveness of the tivoli DES and the firebird DES for treatment of coronary revascularization; PCI, percutaneous coronary intervention; BID, twice daily; DES, drug-eluting stents.

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Rev. Cardiovasc. Med. Print ISSN 1530-6550 Electronic ISSN 2153-8174