Key result
Reducing DAPT intensity cuts major bleeding ~22%, while DAPT abbreviation reduces NACE.
Why the study?
Guideline-recommended 12-month DAPT increases bleeding in ACS, with East Asians showing higher bleeding and lower ischemic risk than non-East Asians.
Does reduction of DAPT intensity or duration reduce bleeding without increasing ischemic events in East Asian compared to non-East Asian ACS patients undergoing PCI?
Meta-Analysis
Yes
Does reduction of DAPT intensity or duration reduce bleeding without increasing ischemic events in East Asian compared to non-East Asian ACS patients undergoing PCI?
Effect estimate: OR 0.78 (95% CI 0.65-0.94)
p-value: p=0.009
DAPT de-escalation strategies safely reduce bleeding in East Asian patients with ACS undergoing PCI, but reducing DAPT intensity may increase ischemic risk in non-East Asian patients.
Supports DAPT de-escalation to cut bleeding in East Asian ACS-PCI patients; extends evidence for ethnicity-specific tailoring.
Background Guideline-recommended dual antiplatelet therapy (DAPT; aspirin plus prasugrel/ticagrelor) for 12 months in acute coronary syndrome (ACS) patients increases bleeding, with East Asians (EAs) exhibiting higher bleeding and lower ischemic risk, compared with non-East Asians (nEAs). We sought to compare DAPT “de-escalation” strategies in EA and nEA populations. Methods A systematic review and meta-analysis of randomized controlled trials assessing reduction of DAPT intensity or duration in ACS patients undergoing percutaneous coronary intervention, in EA and nEA, was performed using a random-effects model. Results Twenty-three trials assessed reduction of DAPT intensity (n = 12) or duration (n = 11). Overall, reduced DAPT intensity attenuated major bleeding (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65–0.94, p = 0.009), without impacting net adverse cardiovascular events (NACE) or major adverse cardiovascular events (MACE). In nEA, this increased MACE (OR: 1.20, 95% CI: 1.09–1.31, p < 0.0001) without impacting NACE or bleeding; while in EA, it reduced major bleeding (OR: 0.71, 95% CI: 0.53–0.95, p = 0.02) without affecting NACE or MACE. Overall, abbreviation of DAPT duration reduced NACE (OR: 0.90, 95% CI: 0.82–0.99, p = 0.03) due to major bleeding (OR: 0.69, 95% CI: 0.53–0.99, p = 0.006), without impacting MACE. In nEA, this strategy did not impact NACE, MACE, or major bleeding; while in EA, it reduced major bleeding (OR: 0.60, 95% CI: 0.4–0.91, p = 0.02) without impacting NACE or MACE. Conclusion In EA, reduction of DAPT intensity or duration can minimize bleeding, without safety concerns. In nEA, reduction of DAPT intensity may incur an ischemic penalty, while DAPT abbreviation has no overall benefit.
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Gorog et al. (2023) conducted a meta-analysis in Acute coronary syndrome (ACS). Reduction of DAPT intensity or duration vs. Standard 12-month DAPT was evaluated on Major bleeding (reduced DAPT intensity) (OR 0.78, 95% CI 0.65-0.94, p=0.009). Reduction of DAPT intensity attenuated major bleeding overall (OR 0.78; 95% CI 0.65-0.94; p=0.009), while DAPT abbreviation reduced NACE (OR 0.90; 95% CI 0.82-0.99; p=0.03).
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