August 1, 2017
View Full PaperState of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation – past, present and future perspectives
Key Result
Extending dual antiplatelet therapy from 3-6 months to 12 months showed no credible increase in all-cause mortality (OR 0.98; 95% BCI 0.73-1.43).
Structured PICO
Does extending the duration of dual antiplatelet therapy improve outcomes in patients after percutaneous coronary intervention with drug-eluting stents?
P
Population
Patients receiving drug-eluting stents (DES) for stable ischaemic heart disease or acute coronary syndrome
I
Intervention
Extended duration dual antiplatelet therapy (DAPT) (e.g., 12 to 18-48 months)
C
Comparator
Shorter duration dual antiplatelet therapy (DAPT) (e.g., 3 to 6 months)
O
Outcome
All-cause mortality, ischaemic events, and bleedinghard clinical
Extending DAPT beyond 12 months after PCI reduces ischaemic events but increases bleeding, without a credible increase in all-cause mortality.
Main Result
Effect estimate: OR 0.98 (95% CI 0.73-1.43)
Abstract
Evidence from studies published more than 10 years ago suggested that patients receiving first-generation drug-eluting stents (DES) needed dual antiplatelet therapy (DAPT) for at least 12 months. Current evidence from randomised controlled trials (RCT) reported within the past five years suggests that patients with stable ischaemic heart disease who receive newer-generation DES need DAPT for a minimum of three to six months. Patients who undergo stenting for an acute coronary syndrome benefit from DAPT for at least 12 months, but a Bayesian network meta-analysis confirms that extending DAPT beyond 12 months confers a trade-off between reduced ischaemic events and increased bleeding. However, the network meta-analysis finds no credible increase in all-cause mortality if DAPT is lengthened from three to six months to 12 months (posterior median odds ratio OR 0.98; 95% Bayesian credible interval BCI: 0.73-1.43), from 12 months to 18-48 months (OR 0.87; 95% BCI: 0.64-1.17), or from three to six months to 18-48 months (OR 0.86; 95% BCI: 0.63-1.21). Future investigation should focus on identifying scoring systems that have excellent discrimination and calibration. Although predictive models should be incorporated into systems of care, most decisions about DAPT duration will be based on clinical judgement and patient preference.