Dual antiplatelet therapy de-escalation by discontinuation in patients with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

BACKGROUND: De-escalation of dual antiplatelet therapy (DAPT) by early discontinuation of one antiplatelet agent has been proposed as an alternative to 12-month DAPT to balance ischemic and bleeding risks in patients with acute coronary syndrome (ACS). However, the efficacy and safety of abbreviated DAPT regimens in ST-elevation myocardial infarction (STEMI) - a subset of ACS with distinct clinical and risk profiles - remain uncertain. METHODS: Randomized trials and sub-analyses of randomized trials comparing DAPT de-escalation by early discontinuation versus 12-month DAPT in patients with STEMI treated with primary angioplasty were included. Co-primary endpoints were major bleeding and major adverse cardiovascular events (MACE). Secondary endpoints included net adverse clinical events (NACE), individual ischemic outcomes, and clinically relevant bleeding. Trial sequential analysis (TSA) and sensitivity analyses were prespecified (CRD42024608709). RESULTS: Eight randomized trials encompassing 10,216 patients were included. Short DAPT regimens significantly reduced major bleeding [hazard ratio, 0.50; 95% confidence interval (CI), 0.30-0.85; P = 0.011] compared with standard DAPT. No significant differences were observed in MACE (hazard ratio, 1.21; 95% CI, 0.91-1.64; P = 0.193) or NACE (hazard ratio, 0.94; 95% CI, 0.80-1.10; P = 0.427). The results of TSA reinforced these findings. Other secondary outcomes showed no significant differences, but interpretation was limited by the small number of studies reporting these events. CONCLUSION: Abbreviated DAPT significantly reduces major bleeding risk in patients with STEMI compared with standard 12-month DAPT, without apparently compromising ischemic protection. However, further research is needed to clarify net clinical outcomes in this high-risk ACS subset. PROTOCOL REGISTRATION IDENTIFIER: CRD42024608709.