Physicians may be overlooking patients’ desire to avoid dual antiplatelet therapy drawbacks

A patient’s preferences should be taken into account when choosing a stent

A study, published in Catheterization and Cardiovascular Interventions, found that most patients undergoing coronary angiography believe that—following percutaneous coronary intervention (PCI)—avoiding dual antiplatelet therapy (DAPT) drawbacks is as important as avoiding repeat revascularisation. It also found that 85% of those who go on to have PCI receive a drug-eluting stent, which suggests that the physician treating them does not take into account their preference to avoid the drawbacks of DAPT (ie. implanting a bare metal stent may be more in line with their wishes).

Study authors Mohammed Qintar (Saint Luke’s Mid America Heart Institute, Division of Cardiology, Kansas, USA) and others report that as drug-eluting stents are used in the majority of PCI cases, physicians may value the need to avoid target vessel revascularisation above the need to avoid the drawbacks of DAPT—which needs to be given for “at least six months” after the implantation of a drug-eluting stent but only needs to be given for one month after the implantation of a bare metal stent. They add that patients may also see avoiding repeating revascularisation as more important than avoiding the drawbacks of DAPT but that “this has never been tested”. Furthermore, Qintar et al note that only 31% of patients recall discussing stent options with their physicians despite 90% of patients expressing a desire to do so. “We thus designed a prospective study to survey patients prior to coronary angiography to investigate the relative importance of avoiding repeat revascularisation as compared with the potential drawbacks associated with prolonged DAPT,” the authors state.

Of 311 patients surveyed, 14.4% considered avoiding a repeat revascularisation as the single most important factor when deciding on a choice of stent but 20.6% considering avoiding one of the DAPT drawbacks as the most important. Qintar et al comment: “Most interestingly, patients who valued avoiding DAPT (more than they valued avoiding a repeat procedure) were more likely to have undergone a PCI within the past six months.” The remaining patients (65%) saw avoiding the drawbacks of DAPT as equally important as avoiding repeat revascularisation.

Of the 60.6% of patients who subsequently underwent PCI, 85% were treated with a drug-eluting stent and there were no differences in drug-eluting stent use between those who most valued avoiding repeat revascularisation, most valued avoiding the drawbacks of DAPT, and those who valued both equally.

According to the authors, if patient preference had been taken into account, “one would expect patients who clearly valued drug-eluting stent benefits the most [ie. wanted less repeat revascularisation] to receive a drug-eluting stent and those clearly valued avoiding DAPT drawbacks the most to receive a bare metal stent”. They add that the rate of drug-eluting stent use “would be much lower than 85%” even if only a small proportion of those who valued avoiding repeat revascularisation and DAPT drawbacks equally had received a bare metal stent. “These data underscore the need for more systematically eliciting patient preferences for stent type prior to PCI,” Qintar et al write.

They conclude: “Explicitly eliciting patients’ preferences is important to better tailor stent choice to the goals and values of individual patients undergoing PCI.”

Adnan Chhatriwalla

Study author Adnan K Chhatriwalla (Saint Luke’s Mid America Heart Institute, Division of Cardiology, Kansas, USA) told Cardiovascular News: “In a prior survey of patients undergoing PCI, we found that less than 5% of patients stated that they alone, or the doctor alone, should decide which treatment option is best.  In other words, the vast majority of patients want to decide along with their doctor which treatment option is best.  When I speak with patients prior to their procedures, I try to give them an overview of stent types and the need to take DAPT. If they are at high-risk for restenosis based on their clinical characteristics, and would benefit more from drug-eluting stents, I do make that recommendation to them. However, I also review the need to take prolonged DAPT and ask them for their opinion regarding stent choice and their ability to take the medication. The bottom line is that no matter what the physician thinks is best, the patient should have a voice in decision-making and the best method to ensure that patient preferences are being understood is to engage patients in the process.”