Shorter vs. Standard Duration of Dual Antiplatelet Therapy in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Abstract Background Current guidelines recommend dual antiplatelet therapy (DAPT) for 12 months following percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) patients; however, prolonged DAPT increases bleeding risk. The optimal duration or strategy for DAPT, particularly in high bleeding risk (HBR) patients, remains unclear. This systematic review and meta-analysis comprehensively evaluated randomized controlled trials (RCTs) comparing short-duration (≤ 6 months) or early de-escalation strategies with standard-duration (12 months) DAPT in ACS patients undergoing PCI. Methods Following PRISMA guidelines, we systematically searched PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov from January 2014 to March 2024. Only RCTs comparing short (≤ 6 months) or de-escalated DAPT versus standard 12-month therapy in ACS patients undergoing PCI were included. Primary outcomes were ischemic events (cardiovascular death, myocardial infarction, stroke) and bleeding events (BARC ≥ 3). Secondary outcomes included stroke, mortality, and stent thrombosis. Random-effects meta-analysis provided pooled risk ratios (RRs) and 95% confidence intervals (CIs), with heterogeneity assessed by I² and subgroup analyses conducted. Results Eight high-quality RCTs enrolling 28,979 patients were included. Short-duration or early de-escalation of DAPT significantly reduced bleeding risk (RR = 0.49; 95% CI: 0.32–0.75; I²=54.6%; p = 0.001) without increasing ischemic outcomes (RR = 0.95; 95% CI: 0.87–1.03; I²=0%; p = 0.20). Subgroup analyses showed significant risk reductions in stroke (RR = 0.77; 95% CI: 0.63–0.94), mortality (RR = 0.82; 95% CI: 0.71–0.94), and stent thrombosis (RR = 0.73; 95% CI: 0.57–0.95), all without significant heterogeneity (I²=0%). Conclusion In ACS patients undergoing PCI, shorter-duration (≤ 6 months) or early de-escalation of DAPT significantly reduces bleeding events and improves net clinical benefit without compromising ischemic safety. These findings strongly support tailored DAPT strategies in clinical practice, particularly for patients at high bleeding risk.