Dual antiplatelet therapy duration after percutaneous coronary intervention in patients with indication to oral anticoagulant therapy. A systematic review and meta-analysis of randomized controlled trials

Claudio Montalto; Francesco Costa; Antonio Micari; Jacopo Oreglia; Pascal Vranckx; Davide Capodanno; Jurriën M. ten Berg; Renato D. Lópes; Marco Valgimigli

doi:10.1093/ehjcvp/pvac065

November 25, 2022European Heart Journal - Cardiovascular Pharmacotherapy

Dual antiplatelet therapy duration after percutaneous coronary intervention in patients with indication to oral anticoagulant therapy. A systematic review and meta-analysis of randomized controlled trials

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Why the study?

The optimal duration of dual antiplatelet therapy in patients with a concomitant indication for oral anticoagulation remains debated.

Does an abbreviated DAPT regimen reduce bleeding without increasing ischemic events compared to prolonged DAPT in patients undergoing PCI with an indication for OAC?

Structured PICO

Does an abbreviated DAPT regimen reduce bleeding without increasing ischemic events compared to prolonged DAPT in patients undergoing PCI with an indication for OAC?

P

Population

7,665 patients undergoing percutaneous coronary intervention (PCI) with concomitant indication to oral anticoagulation (OAC) from 5 randomized controlled trials

I

Intervention

Abbreviated dual antiplatelet therapy (DAPT) regimen (peri-procedural or short 4-6 weeks)

C

Comparator

Prolonged (≥3 months) DAPT regimen

O

Outcome

Co-primary endpoints: major or clinically relevant non-major bleedings (MCRB) and major bleedingsafety

Implication

In patients undergoing PCI with an indication for OAC, an abbreviated DAPT regimen reduces major and clinically relevant non-major bleeding without increasing ischemic events compared to prolonged DAPT.

Abstract

AIMS: Optimal duration of dual antiplatelet therapy (DAPT) in patients with concomitant indication to oral anticoagulation (OAC) is still debated. METHODS AND RESULTS: A systematic review was performed on electronic databases to search for randomized controlled trials comparing an abbreviated or prolonged (≥3 months) DAPT regimen in patients with OAC and they were analysed in the framework of standard and network meta-analyses. Co-primary endpoints were major or clinically relevant non-major bleedings (MCRB) and major bleeding, while the composite of major adverse cardiovascular events (MACE) was the key safety endpoint. Five studies and 7 665 patients (abbreviated DAPT n = 3 843; prolonged DAPT n = 3 822) were included. Both MCRB and major bleeding were lower with abbreviated DAPT [risk ratio (RR) 0.69 (0.52-0.91); P = 0.01 and 0.70 (0.52-0.95); P = 0.01, respectively] while MACE [RR: 0.96 (0.70-1.33); P = 0.6], all-cause death, cardiovascular death, stent thrombosis, or myocardial infarction did not differ. Network meta-analysis showed that peri-procedural DAPT had the highest probability to prevent MCRB and major bleeding (97.1 and 92.0% respectively) when compared with both short (4-6 weeks) and longer (≥3 months) DAPT regimens. Sensitivity analyses and meta-regressions showed consistency in different clinical scenarios and suggested a larger bleeding reduction with P2Y12 inhibitors vs. aspirin after DAPT discontinuation. CONCLUSION: In patients undergoing PCI with concomitant OAC indication, an abbreviated DAPT regimen reduced MCRB and major bleeding without increasing MACE or other ischaemic events. Peri-procedural DAPT and P2Y12 inhibitor monotherapy after DAPT withdrawal appear to be the best strategies to optimize the bleeding and ischaemic risk tradeoff. Trial registration. PROSPERO CRD284001.