October 9, 2024JAMA Cardiology22 citationsOpen Access
View Full PaperShort-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes
Structured PICO
Does short-term dual antiplatelet therapy reduce major bleeding or MACCE compared to 12 months of DAPT in patients with acute coronary syndromes undergoing PCI?
P
Population
15 RCTs pooling 35,326 patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). Mean age 63.1 years, 76.3% male, 32.1% STEMI. 70.2% received potent P2Y12 inhibitors (ticagrelor or prasugrel).
I
Intervention
Short-term dual antiplatelet therapy (DAPT) strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin)
C
Comparator
Conventional 12 months of dual antiplatelet therapy (DAPT)
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Outcome
Major adverse cardiac and cerebrovascular events (MACCE) (primary efficacy end point) and major bleeding (primary safety end point)composite
In patients with ACS undergoing PCI, 1 month of DAPT followed by P2Y12 inhibitor monotherapy reduces major bleeding without significantly increasing MACCE compared to 12 months of DAPT.
Abstract
Importance: The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate. Objectives: To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis. Data Sources: MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024. Study Selection: Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT. Data Extraction and Synthesis: This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA). Main Outcomes and Measures: The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding. Results: A total of 15 RCTs randomizing 35 326 patients (mean SD age, 63.1 11.1 years; 26 954 male 76.3%; 11 339 STEMI 32.1%) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21). Conclusion and Relevance: Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.