Extended Dual Antiplatelet Therapy Versus Aspirin Monotherapy After Drug-Eluting Stent Implantation

The optimal duration of dual antiplatelet therapy (DAPT) following drug-eluting stent implantation remains uncertain. We evaluated extended DAPT versus aspirin monotherapy in patients who completed approximately 12 months of uneventful DAPT after percutaneous coronary intervention. PubMed, Embase, and Web of Science were searched through August 2026 for randomized controlled trials comparing these strategies. The primary outcome was myocardial infarction (MI); secondary outcomes included all-cause mortality, cardiac death, stent thrombosis, repeat revascularization, stroke, and clinically relevant bleeding (Bleeding Academic Research Consortium type 2-5). Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a Mantel-Haenszel random-effects model. Certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE), and trial sequential analysis was performed for MI. Six trials involving 28,601 patients were included. Extended DAPT significantly reduced MI compared with aspirin monotherapy (RR, 0.66; 95% CI, 0.51-0.85; P = 0.001; I2 = 37%). No significant differences were observed in all-cause mortality, cardiac death, stent thrombosis, repeat revascularization, or stroke. Clinically relevant bleeding was also not significantly different (RR, 1.19; 95% CI, 0.66-2.15; P = 0.56), although substantial heterogeneity was observed (I2 = 87%) and certainty was low. GRADE certainty was high for MI, cardiac death, and repeat revascularization; moderate for all-cause mortality; and low for stent thrombosis and bleeding. Trial sequential analysis for MI crossed the conventional significance boundary but not the trial sequential monitoring boundary or required information size. Extended DAPT may reduce MI, but individualized assessment of ischemic and bleeding risk remains important, and further adequately powered trials are warranted.