Individualizing Treatment Duration of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention: An Analysis from the DAPT Study Robert W. Yeh, Eric A. Secemsky, Dean J. Kereiakes, Sharon-Lise T. Normand, Anthony H. Gershlick, David J. Cohen, John A. Spertus, P. Gabriel Steg, Donald E. Cutlip, Michael J. Rinaldi, Edoardo Camenzind, William Wijns, Patricia K. Apruzzese, Yang Song, Joseph M. Massaro, and Laura Mauri, for the Dual Antiplatelet Therapy (DAPT) Study Investigators

Disclosures Funding The DAPT Study was sponsored by Harvard Clinical Research Institute, and funded by Abbott, Boston Scientific Corporation, Cordis Corporation, Medtronic, Inc., Bristol-Myers Squibb Company/Sanofi Pharmaceuticals Partnership, Eli Lilly and Company, and Daiichi Sankyo Company Limited and the US Department of Health and Human Services (1RO1FD003870-01). This analysis was supported by the National Heart, Lung and Blood Institute (K23HL118138) and Harvard Clinical Research Institute. Disclosures Personal fees from Abbott Vascular, Boston Scientific, and Merck.

Risk Difference (Continued Thienopyridine – Placebo), 12-30M Background In the DAPT Study, continuation of dual antiplatelet therapy beyond 12 months reduced ischemic complications after coronary stenting compared with aspirin alone, yet increased moderate or severe bleeding. Risk Difference (Continued Thienopyridine – Placebo), 12-30M Stent Thrombosis Death, MI, Or Stroke (MACCE) Myocardial Infarction GUSTO Mod/Severe Bleed Death HR 0.47 (0.37–0.61) P<0.001 HR 0.71 (0.59–0.85) P<0.001 Mauri, Kereiakes, Yeh et al. NEJM. 2014 Dec 4:371:2155-66.

Objective To develop a decision tool to identify whether an individual patient is more likely to derive benefit or harm from continuation of dual antiplatelet therapy beyond 1 year. Simultaneously accounting for risks of ischemia AND bleeding with continued therapy.

Design Inclusion: FDA-approved DES or BMS, candidates for thienopyridine Excluded: Oral anticoagulant therapy; life expectancy < 3y Randomized: Free from MI, stroke, repeat revascularization, moderate/severe bleeding, and adherent with therapy at 12 months Mauri, Kereiakes et al. AHJ. 2010;160(6): 1035-41. ClinicalTrials.gov number NCT00977938 5 5 5

Methods – Models to Predict Ischemic and Bleeding Events Development of 2 Prediction Models within the randomized DAPT Study population (N=11648). Ischemic Model: Myocardial infarction or stent thrombosis between 12-30 months after index PCI. Includes fatal events. Bleeding Model: GUSTO moderate or severe bleeding between 12-30 months after index PCI. Includes fatal events. Cox regression, stepwise selection among 37 candidate variables, including randomized treatment arm. In addition, several interaction terms with treatment arm evaluated. P value of 0.05 for retention. Validated externally within the PROTECT trial population* *Camenzind, Wijns, Mauri et al. Lancet. 380;9851:1396-1405.

Methods – Predicting Net Treatment Effect Predicted Ischemic Event Rate with Placebo Predicted Ischemic Event Rate with Rx Predicted Bleeding Event Rate with Rx Predicted Bleeding Event Rate with Placebo Predicted Risk Reduction in Ischemic Events (Beneficial Effect) Predicted Risk Increase in Bleeding Events (Harmful Effect) Predicted Net Treatment Effect (Range from Negative to Positive) Predictors of net treatment effect with continued thienopyridine determined from linear regression and simplified to an integer point score (DAPT Score) Actual outcomes presented by randomized treatment arm stratified by DAPT Score. Sensitivity analysis without paclitaxel-eluting stent-treated subjects.

Baseline Characteristics; All Randomized Patients With vs Baseline Characteristics; All Randomized Patients With vs. Without Ischemic or Bleeding Events   Myocardial Infarction or Stent Thrombosis Events GUSTO Severe/Moderate Events Measure* MI or Stent Thrombosis N=348 No MI or Stent Thrombosis N=11300 P Bleeding N=215 No Bleeding N=11433 Age (years) 61.7 61.3 0.47 66.4 61.2 <.001 Female 26.4% 25.1% 0.57 29.3% 25.0% 0.15 BMI (Kg/m2) 30.1 30.4 0.28 29.5 0.01 Diabetes mellitus 39.9% 28.9% 31.3% 29.2% 0.50 Hypertension 81.0% 73.1% 84.2% 73.2% Cigarette smoker 33.0% 27.2% 0.02 18.2% 27.6% 0.002 Congestive heart failure 10.4% 4.3% 8.0% 4.5% LVEF < 30% 4.6% 1.9% 3.1% Prior PCI 42.4% 28.6% 37.7% Prior CABG 17.5% 10.5% 14.4% 10.7% 0.09 Prior myocardial infarction 32.7% 21.1% 22.2% 21.4% 0.80 Indication for index procedure STEMI 1.00 10.2% 14.5% 0.08 NSTEMI 22.1% 16.1% 0.004 12.1% 16.4% 0.11 Renal insufficiency/failure 7.9% 3.9% 0.001 9.4% Peripheral arterial disease 10.9% 5.5% 14.3% Continued thienopyridine 35.3% 50.8%  < 0.001 62.8% 50.1% < 0.001 

Multivariable Prediction Models Predictors of Myocardial Infarction or Stent Thrombosis Predictors of Moderate/Severe Bleeding Predictors of Events HR (95% CI) P Continued Thienopyridine vs. Placebo 0.52 (0.42 – 0.65) <0.001 1.66 (1.26 - 2.19) MI at Presentation 1.65 (1.31 – 2.07) - Prior PCI or Prior MI 1.79 (1.43 – 2.23) CHF or LVEF < 30% 1.88 (1.35 – 2.62) Vein Graft PCI 1.75 (1.13 – 2.73) 0.01 Stent Diameter < 3 mm 1.61 (1.30 – 1.99) Paclitaxel-Eluting Stent 1.57 (1.26 – 1.97) Cigarette Smoker 1.40 (1.11 – 1.76) Diabetes 1.38 (1.10 – 1.72) Peripheral Arterial Disease 1.49 (1.05 – 2.13) 0.03 2.16 (1.46, 3.20) Hypertension 1.37 (1.03 – 1.82) 1.45 (1.00, 2.11) 0.05 Renal Insufficiency 1.55 (1.03 – 2.32) 0.04 1.66 (1.04, 2.66) Age (per 10 years) 1.54 (1.34, 1.78) *The ischemia model C-statistic: 0.70 in DAPT Study; 0.64 in PROTECT **The bleeding model C-statistic: 0.68 in DAPT Study; 0.64 in PROTECT

Predictors of Net Treatment Effect Characteristics Impact on Net Treatment Effect % of Variation Explained Age ≥ 75 Age 65 - < 75 Age < 65 (reference) -1.2% -0.5% - 6.0% 2.1% Prior PCI or MI 1.1% 14.6% Stent Diameter < 3 mm 0.9% 10.1% CHF or LVEF < 30% 1.9% 9.9% MI at Presentation 1.0% 9.6% Paclitaxel-Eluting Stent 8.8% Cigarette Smoker 0.7% 4.3% Diabetes 0.6% Vein Graft PCI 1.6% 3.7% Hypertension 0.2% 0.4% Renal Insufficiency 0.3% PAD -0.1% 0.04% Bleeding Predictors Ischemia Predictors Bleeding and Ischemia Predictors

The DAPT Score Variable Points Patient Characteristic Age ≥ 75 -2 65 - <75 -1 < 65 Diabetes Mellitus 1 Current Cigarette Smoker Prior PCI or Prior MI CHF or LVEF < 30% 2 Index Procedure Characteristic MI at Presentation Vein Graft PCI Stent Diameter < 3mm Distribution of DAPT Scores among all randomized subjects in the DAPT Study

Risk Difference (Continued Thienopyridine – Placebo), 12-30M Continued Thienopyridine vs. Placebo Treatment Effect by DAPT Score Quartile (N = 11,648) Q1 = DAPT Score -2 to 0 Q3 = DAPT Score 2 Q2 = DAPT Score 1 Q4 = DAPT Score > 2 Risk Difference (Continued Thienopyridine – Placebo), 12-30M Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Risk Difference (Continued Thienopyridine – Placebo), 12-30M Continued Thienopyridine vs. Placebo Treatment Effect by DAPT Score Quartile (N = 11,648) Risk Difference (Continued Thienopyridine – Placebo), 12-30M Mortality Net Adverse Events Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 DAPT Score < 2 DAPT Score ≥ 2 DAPT Score < 2 DAPT Score ≥ 2 13 13

Continued Thienopyridine vs. Placebo DAPT Score <2 (Low); N=5731 Myocardial Infarction or Stent Thrombosis Death, MI, or Stroke (MACCE) 10% Continued Thienopyridine Placebo 10% Continued Thienopyridine Placebo 8% 8% 6% 6% Cumulative Incidence of ST/MI Cumulative Incidence of MACCE 4% 1.7% vs. 2.3% P=0.07 4% 3.7% vs. 3.8% P=0.73 2% 2% 0% 0% 12 15 18 21 24 27 30 12 15 18 21 24 27 30 Months After Enrollment Months After Enrollment 10% Continued Thienopyridine Placebo 8% GUSTO Moderate/ Severe Bleeding 6% Cumulative Incidence of GUSTO Moderate/ Severe Bleed 4% 3.0% vs. 1.4% P<0.001 2% 0% 12 15 18 21 24 27 30 Months After Enrollment

Continued Thienopyridine vs. Placebo DAPT Score ≥ 2 (High); N=5917 Myocardial Infarction or Stent Thrombosis Death, MI or Stroke (MACCE) 10% Continued Thienopyridine Placebo 10% Continued Thienopyridine Placebo 8% 8% 6% 6% 4.9% vs. 7.6% P<0.001 Cumulative Incidence of ST/MI 2.7% vs. 5.7% P<0.001 Cumulative Incidence of MACCE 4% 4% 2% 2% 0% 0% 12 15 18 21 24 27 30 12 15 18 21 24 27 30 Months After Enrollment Months After Enrollment 10% Continued Thienopyridine Placebo 8% GUSTO Moderate/ Severe Bleeding 6% Cumulative Incidence of GUSTO Moderate/ Severe Bleed 1.8% vs. 1.4% P=0.26 4% 2% 0% 12 15 18 21 24 27 30 Months After Enrollment

Continued Thienopyridine vs. Placebo High vs. Low DAPT Score Myocardial Infarction or Stent Thrombosis GUSTO Moderate or Severe Bleed Net Adverse Events Mortality (Continued Thienopyridine – Placebo), 12-30M Risk Difference P<0.001 P=0.02 P<0.001 P=0.14 P values are for comparison of risk differences across DAPT Score category (interaction).

Continued Thienopyridine vs. Placebo, by DAPT Score, Excluding PES Myocardial Infarction or Stent Thrombosis GUSTO Moderate or Severe Bleed Net Adverse Events Mortality (Continued Thienopyridine – Placebo), 12-30M Risk Difference P=0.06 P=0.07 P=0.003 P=0.17 P values are for comparison of risk differences across DAPT Score category (interaction).

Limitations Modest discrimination of ischemic and bleeding models Greater than values observed in many validation cohorts for the CH2AD2-VASC or HAS-BLED Scores* In PROTECT, high DAPT score patients had higher ischemic risk (HR 2.01, p = 0.002) AND trend toward lower bleeding risk (HR 0.69, p = 0.31), compared with low DAPT score patients Post hoc analysis, not powered to examine differences in individual outcomes between subgroups Limited ability to identify rare or unmeasured predictors of events Models not evaluated in patients receiving ticagrelor or other antiplatelet combinations *Lip et al. Chest. 2010;137(2):263-272. Lip et al. JACC 2011:57(2):173-180.

Conclusions DAPT Score may help clinicians decide who should, Among patients who have not had a major ischemic or bleeding event within the first year after PCI: The DAPT Score identified patients for whom ischemic benefits outweighed bleeding risks, and patients for whom bleeding risks outweighed ischemic benefits. Low DAPT Score (< 2) NNT to prevent ischemia = 153 NNH to cause bleeding = 64 High DAPT Score ≥ 2 NNT to prevent ischemia = 34 NNH to cause bleeding = 272 -2 10 DAPT Score may help clinicians decide who should, and who should not be treated with extended DAPT

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