Dual antiplatelet therapy duration after percutaneous coronary intervention with contemporary drug-eluting stents: A systematic review and network meta-analysis of randomized trials

Figures

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  Fig 1. PRISMA flow chart of trial selection. Flow diagram illustrating the study selection process. DAPT = dual antiplatelet therapy; PRISMA = Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

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  Fig 2. Summary of risk of bias across included randomized trials. Risk of bias for each included randomized trial was evaluated using the Cochrane RoB 2 tool across five domains (D1 to D5). Domain-specific and overall judgments are displayed for each study. Green (+) indicates low risk, yellow (-) indicates some concerns, and red (x) indicates high risk of bias.

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  Fig 3. Network maps of dual antiplatelet therapy duration for major adverse cardiovascular events and major bleeding. Each node represents a dual antiplatelet therapy (DAPT) duration, and node size is proportional to the number of patients assigned to that treatment across included trials. Connecting lines indicate direct comparisons between treatment strategies. Line thickness reflects the number of trials contributing to each direct comparison. In panel A (major adverse cardiovascular events), the network includes four DAPT duration nodes (1 month, 3 months, 6 months, and 12 months). In panel B (major bleeding), an additional node (>12 months) is included based on available data from trials reporting bleeding outcomes. m = months.

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  Fig 4. Forest plots comparing dual antiplatelet therapy durations for major adverse cardiovascular events. Forest plots show pairwise comparisons of dual antiplatelet therapy (DAPT) durations for major adverse cardiovascular events derived from the network meta-analysis. Blue squares represent individual trial estimates with corresponding 95% confidence intervals (horizontal lines). Green squares represent pooled direct estimates from conventional meta-analyses, and red squares represent pooled network estimates. The size of the squares is proportional to study weight. Risk ratios (RRs) are presented on a logarithmic scale; values <1 or >1 should be interpreted based on the direction of the comparison. The vertical reference line indicates no difference (RR = 1). m = months.

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  Fig 5. Surface Under the Cumulative Ranking Curve (SUCRA)- based ranking probabilities of dual antiplatelet therapy durations for major adverse cardiovascular events. Bar chart showing the probability of each dual antiplatelet therapy (DAPT) duration strategy ranking at each position (best, second, third, or worst) for major adverse cardiovascular events (MACE), based on the network meta-analysis. Ranking probabilities were derived from the relative treatment effects across the network using a frequentist framework. Each bar represents the probability of a given DAPT duration (1 month, 3 months, 6 months, and 12 months) being ranked at a specific position. The “best” rank indicates the highest probability of achieving the most favorable outcome (lowest risk of MACE), whereas the “worst” rank indicates the least favorable outcome. m = months.

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  Fig 6. Forest plots comparing dual antiplatelet therapy durations for major bleeding. Forest plots showing pairwise comparisons of dual antiplatelet therapy (DAPT) durations for major bleeding derived from the network meta-analysis. Blue squares represent individual trial estimates with corresponding 95% confidence intervals (horizontal lines). Green squares represent pooled direct estimates from conventional meta-analyses, and red squares represent pooled network estimates. The size of the squares is proportional to study weight. Risk ratios (RRs) are presented on a logarithmic scale, with direction of effect determined by the order of treatment comparison. The vertical reference line indicates no difference (RR = 1). m = months.

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  Fig 7. Surface Under the Cumulative Ranking Curve (SUCRA)- based ranking probabilities of dual antiplatelet therapy durations for major bleeding. Bar chart shows the probability of each dual antiplatelet therapy (DAPT) duration strategy ranking at each position (best, second, third, fourth, or worst) for major bleeding, based on the network meta-analysis. Ranking probabilities were derived from the relative treatment effects across the network using a frequentist framework. Each bar represents the probability of a given DAPT duration (1 month, 3 months, 6 months, 12 months, and >12 months) being ranked at a specific position. The “best” rank indicates the lowest risk of major bleeding, whereas the “worst” rank indicates the highest risk.