Long-term DAPT reduced ischemic events in non-high bleeding risk patients after complex PCI (ARD -3.86%; 95% CI -7.71 to +0.06), but increased bleeding in high bleeding risk patients.
Meta-Analysis (n=14,963)
Randomly allocated
Yes
Effect estimate: ARD -3.86% (95% CI -7.71 to +0.06)
BACKGROUND: Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. OBJECTIVES: This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. METHODS: Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. RESULTS: Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: -3.86%; 95% confidence interval: -7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: -1.14%; 95% confidence interval: -2.26 to -0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. CONCLUSIONS: Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT.
“We have a huge number of DAPT studies, and the messages given are not always consistent. First, it is difficult for the clinicians to know about all these studies. Second, even if you want to put the energy into reading all of them, you may be more confused than before. The reason why is because DAPT duration depends on patient characteristics.”
Costa et al. (Fri,) conducted a meta-analysis in Coronary stenting (PCI) (n=14,963). Long-term dual antiplatelet therapy (DAPT) vs. Short-term DAPT was evaluated on Ischemic events (ARD -3.86%, 95% CI -7.71 to +0.06). Long-term DAPT reduced ischemic events in non-high bleeding risk patients after complex PCI (ARD -3.86%; 95% CI -7.71 to +0.06), but increased bleeding in high bleeding risk patients.