What does this research mean for the field?

In East Asian patients with acute coronary syndrome, dual antiplatelet therapy de-escalation significantly reduces the risk of bleeding complications without increasing the risk of major adverse cardiovascular events. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

To assess the effectiveness and safety of dual antiplatelet therapy (DAPT) de-escalation in East Asian individuals post-PCI for acute coronary syndrome (ACS).

February 21, 2026BMC Cardiovascular Disorders0 citationsOpen Access

Efficacy and safety of dual antiplatelet therapy de-escalation in East Asian individuals following percutaneous coronary intervention for acute coronary syndrome: a systematic review and meta-analysis

Q: What is the clinical evidence from this study?

Study design: Systematic Review and Meta-Analysis. Population: East Asian adult patients with acute coronary syndrome undergoing percutaneous coronary intervention (n=10263). Intervention: Dual antiplatelet therapy (DAPT) de-escalation vs. Standard-dose dual antiplatelet therapy with a potent P2Y12 inhibitor. Primary outcome: Major adverse cardiovascular events (MACE): composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke (RR 0.91, 95% CI 0.70-1.19, p=0.497).

ZCZhantao CaoFujian University of Traditional Chinese Medicine JCJingting ChenFujian University of Traditional Chinese Medicine KZKailin ZhengFujian University of Traditional Chinese Medicine

Key Result

DAPT de-escalation reduced bleeding risk by up to 53% without significantly increasing MACE risk (RR 0.91, 95% CI 0.70–1.19, p=0.497) in East Asian ACS patients after PCI.

Key Points

To assess the effectiveness and safety of dual antiplatelet therapy (DAPT) de-escalation in East Asian individuals post-PCI for acute coronary syndrome (ACS).
Conducted a systematic review and meta-analysis
Searched Chinese and English literature databases for cohort studies and RCTs
Included nine studies: five RCTs and four cohort studies totaling 10,263 patients
Analyzed major adverse cardiovascular events (MACE) and bleeding classified by BARC criteria
DAPT de-escalation significantly reduced BARC type 1 bleeding risk (RR = 0.52; p = 0.011)
De-escalation linked to lower BARC type ≥ 2 bleeding risk (RR = 0.47; p < 0.001)
De-escalation also reduced BARC type ≥ 3 events (RR = 0.61; p = 0.026)
No significant difference in MACE risk between de-escalation and standard regimens (RR = 0.91; p = 0.497)

Study Design

Type

Systematic Review and Meta-Analysis (n=10,263)

Structured PICO

Does dual antiplatelet therapy de-escalation reduce bleeding risk without increasing major adverse cardiovascular events in East Asian patients with acute coronary syndrome following percutaneous coronary intervention?

Population

10,263 East Asian patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) pooled from 9 studies (5 RCTs and 4 cohort studies).

Intervention

Dual antiplatelet therapy (DAPT) de-escalation strategies (stepwise reduction in intensity or dosage of antiplatelet agents, such as switching from ticagrelor/prasugrel to clopidogrel, or reduced-dose potent P2Y12 inhibition) after the acute post-PCI phase.

Comparator

Standard intensive dual antiplatelet therapy (DAPT).

Outcome

Major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke, and bleeding outcomes classified according to Bleeding Academic Research Consortium (BARC) criteria.composite

In East Asian patients with ACS undergoing PCI, DAPT de-escalation significantly reduces bleeding complications without a statistically significant increase in ischemic events.

Main Result

Effect estimate: RR 0.91 (95% CI 0.70-1.19)

p-value: p=0.497

Limitations

Inclusion of observational studies potentially introduces residual confounding and treatment-selection bias.
Limited number and size of randomized trials reduce statistical precision for ischemic outcomes.
Heterogeneity in timing and methods of de-escalation across studies may affect comparability.
Low event rates and short follow-up durations limit power to detect differences in ischemic events.
Lack of patient-level data limits analysis of subgroups (e.g., ACS subtypes, bleeding risk scores).
Potential publication and reporting bias due to small number of studies and inclusion of local-language sources.

Abstract

East Asian patients with acute coronary syndrome (ACS) are more prone to bleeding complications than Western populations under comparable antithrombotic regimens. This pattern presents a considerable obstacle to the routine use of intensive dual antiplatelet therapy (DAPT) undergoing percutaneous coronary intervention (PCI). Consequently, the effectiveness and safety of DAPT de-escalation strategies tailored to this particular group of patients remain inadequately defined. An extensive search of both Chinese and English literature databases was performed up to June 2025 to locate cohort studies and randomized controlled trials assessing the effectiveness and safety of de-escalating DAPT in East Asian individuals diagnosed with ACS. The primary outcomes included major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke, and bleeding outcomes, with bleeding classified according to Bleeding Academic Research Consortium (BARC) criteria. Meta-analytical methods were applied using either fixed-effects or random-effects models, depending on data suitability. A total of nine studies were included in the analysis, consisting of five RCTs and four cohort studies, encompassing 10,263 patients overall. Compared to standard DAPT, the de-escalation approach was significantly linked to lower risks of BARC type 1 bleeding (RR = 0.52; 95% CI: 0.32–0.86; p = 0.011), BARC type ≥ 2 bleeding (RR = 0.47; 95% CI: 0.37–0.60; p < 0.001), and BARC type ≥ 3 events (RR = 0.61; 95% CI: 0.40–0.94; p = 0.026). Nonetheless, the comparison between de-escalation and standard regimens revealed no statistically meaningful difference in MACE risk (RR = 0.91; 95% CI: 0.70–1.19; p = 0.497). This result remained stable across the separate elements comprising the MACE composite outcome. Among East Asian patients with ACS, implementing a DAPT de-escalation strategy lowers bleeding risk without elevating ischemic events, suggesting a potentially favorable safety profile in East Asian patients. Further validation by RCTs is warranted.

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Cite This Study

Cao et al. (Tue,) conducted a systematic review and meta-analysis in East Asian adult patients with acute coronary syndrome undergoing percutaneous coronary intervention (n=10,263). Dual antiplatelet therapy (DAPT) de-escalation vs. Standard-dose dual antiplatelet therapy with a potent P2Y12 inhibitor was evaluated on Major adverse cardiovascular events (MACE): composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke (RR 0.91, 95% CI 0.70-1.19, p=0.497). DAPT de-escalation reduced bleeding risk by up to 53% without significantly increasing MACE risk (RR 0.91, 95% CI 0.70–1.19, p=0.497) in East Asian ACS patients after PCI.

synapsesocial.com/papers/69994a7f873532290d01ee89 https://doi.org/https://doi.org/10.1186/s12872-026-05527-z

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