Key result
P2Y12 monotherapy after 1-3 months DAPT yields similar major events versus standard DAPT in complex PCI.
Why the study?
It remained unclear whether P2Y12 inhibitor monotherapy preserves ischemic protection while limiting bleeding risk compared with DAPT after complex PCI.
Meta-Analysis (n=22,941)
Yes
Hazard Ratio: 0.87 (95% CI 0.64–1.19)
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“After a complex PCI - multivessel work, bifurcations, long or calcified lesions - many of us instinctively keep patients on full dual antiplatelet therapy longer, wary of ischemic risk.”
Supports short DAPT then P2Y12 monotherapy in complex PCI to limit bleeding without excess ischemia; leaves open dedicated prospective confirmation.
BACKGROUND It remains unclear whether P2Y12 inhibitor monotherapy preserves ischemic protection while limiting bleeding risk compared with dual antiplatelet therapy (DAPT) after complex percutaneous coronary intervention (PCI). OBJECTIVES We sought to assess the effects of P2Y12 inhibitor monotherapy after 1-month to 3-month DAPT vs standard DAPT in relation to PCI complexity. METHODS We pooled patient-level data from randomized controlled trials comparing P2Y12 inhibitor monotherapy and standard DAPT on centrally adjudicated outcomes after coronary revascularization. Complex PCI was defined as any of 6 criteria: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, or chronic total occlusion. The primary efficacy endpoint was all-cause mortality, myocardial infarction, and stroke. The key safety endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding. RESULTS Of 22,941 patients undergoing PCI from 5 trials, 4,685 (20.4%) with complex PCI had higher rates of ischemic events. The primary efficacy endpoint was similar between P2Y12 inhibitor monotherapy and DAPT among patients with complex PCI (HR: 0.87; 95% CI: 0.64-1.19) and noncomplex PCI (HR: 0.91; 95% CI: 0.76-1.09; Pinteraction = 0.770). The treatment effect was consistent across all the components of the complex PCI definition. Compared with DAPT, P2Y12 inhibitor monotherapy consistently reduced BARC 3 or 5 bleeding in complex PCI (HR: 0.51; 95% CI: 0.31-0.84) and noncomplex PCI patients (HR: 0.49; 95% CI: 0.37-0.64; Pinteraction = 0.920). CONCLUSIONS P2Y12 inhibitor monotherapy after 1-month to 3-month DAPT was associated with similar rates of fatal and ischemic events and lower risk of major bleeding compared with standard DAPT, irrespective of PCI complexity. (PROSPERO [P2Y12 Inhibitor Monotherapy Versus Standard Dual Antiplatelet Therapy After Coronary Revascularization: Individual Patient Data Meta-Analysis of Randomized Trials]; CRD42020176853).
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Gragnano et al. (2023) conducted a meta-analysis in complex percutaneous coronary intervention (PCI) (n=22,941). P2Y12 inhibitor monotherapy vs. standard DAPT was evaluated on all-cause mortality, myocardial infarction, and stroke (HR 0.87, 95% CI 0.64-1.19). P2Y12 inhibitor monotherapy after 1-3 months of DAPT yielded similar rates of mortality, MI, and stroke compared with standard DAPT in complex PCI (HR 0.87; 95% CI 0.64-1.19).
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