guided de-escalation of dapt in acute coronary syndrome patients undergoing percutaneous coronary intervention with bvs implantation: a post-hoc analysis from the randomized tropical-acs trial

To investigate the safety and efficacy of an early platelet function testing (pft)-guided de-escalation of dual antiplatelet treatment (dapt) in acute coronary syndrome (acs) patients undergoing percutaneous coronary intervention (pci) with bioresorbable vascular scaffolds (bvs). early dapt de-escalation is a new non-inferior alternative to 12-months dapt in patients with biomarker positive acs treated with stent implantation. in this post-hoc analysis of the tropical-acs trial, which randomized 2610 acs patients to a pft-guided dapt de-escalation (switch from prasugrel to clopidogrel) or to control group (uniform prasugrel), we compared clinical outcomes of patients (n = 151) who received a bvs during the index pci. the frequency of the primary endpoint (cardiovascular death, myocardial infarction, stroke or barc ≥ 2 bleeding) was 8.8% (n = 6) in the de-escalation group vs. 12.0% (n = 10) in the control group (hr 0.72, 95% ci 0.26–1.98, p = 0.52) at 12 months. one early definite stent thrombosis (st) occurred in the control group (day 19) and 1 possible st (sudden cardiovascular death) in the de-escalation group (day 86), both despite prasugrel treatment and in a background of high on-treatment platelet reactivity assessed at day 14 after randomization (adp-induced platelet aggregation values of 108 u and 59 u, respectively). a pft-guided dapt de-escalation strategy could potentially be a safe and effective strategy in acs patients with bvs implantation but the level of platelet inhibition be of particular importance. this hypothesis-generating post-hoc analysis requires verification in larger studies with upcoming bvs platforms.