June 1, 2023Open Access

Short Versus Long-Term Dual Antiplatelet Therapy in Patients at High Bleeding Risk Undergoing PCI in Contemporary Practice: A Systemic Review and Meta-analysis

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: High bleeding risk undergoing percutaneous coronary intervention (n=15908). Intervention: Short-term dual antiplatelet therapy (DAPT) vs. Long-term DAPT (6-12 months). Primary outcome: Major bleeding events (BARC classification) (OR 0.63, 95% CI 0.42-0.95, p=0.03).

Key Result

Short-term DAPT (1-3 months) reduced major bleeding events (OR 0.63) compared to long-term DAPT (6-12 months) in high bleeding risk patients undergoing PCI, with similar ischemic outcomes.

Study Design

Type

Meta-Analysis (n=15,908)

Multicenter

Yes

Structured PICO

Does short-term DAPT reduce major bleeding events in high bleeding risk patients undergoing PCI with second-generation DES?

Population

15,908 patients fulfilling high bleeding risk (HBR) criteria who underwent percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES)

Intervention

Short-term dual antiplatelet therapy (DAPT) for 1-3 months

Comparator

Long-term dual antiplatelet therapy (DAPT) for 6-12 months

Outcome

Incidence of major bleeding events as defined according to the Bleeding Academic Research Consortium (BARC) classification at 12 months follow-upsafety

In high bleeding risk patients undergoing PCI, 1-3 months of DAPT reduces major bleeding compared to 6-12 months of DAPT, with comparable overall ischemic outcomes, though stroke and MI risks may be elevated in certain subsets.

Main Result

Effect estimate: OR 0.63 (95% CI 0.42-0.95)

Absolute Event Rate: 2.27% vs 3.2%

p-value: p=0.03

Limitations

Considerable degree of heterogeneity regarding the primary outcome
Inclusion of observational studies introduces the risk of selection bias and confounding
Variance introduced by clinical endpoint definitions, especially in bleeding event endpoints

Abstract

Patients at high bleeding risk (HBR patients) represent an important subset of patients undergoing percutaneous coronary intervention (PCI). It remains unclear whether a shortened duration of dual antiplatelet therapy (DAPT) confers benefits compared with prolonged duration of DAPT in this patient population. The aim of this study was to investigate and compare bleeding and ischemic outcomes among HBR patients receiving short- versus long-term DAPT after PCI. A meta-analysis of studies comparing short-term (1–3 months) and long-term (6–12 months) DAPT after PCI with second-generation drug-eluting stents in HBR patients was performed. Six studies 1 randomized controlled trial (RCT), 2 RCT subanalyses, and 3 prospective propensity-matched studies involving 15,908 patients were included in the meta-analysis. During a follow-up of 12 months, short-term DAPT was associated with a reduction in major bleeding events odds ratio (OR) 0.63, 95% confidence interval (CI) 0.42–0.95; p = 0.03, I2 = 71 and comparable definite/probable stent thrombosis, all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and ischemic stroke, compared with long-DAPT. Single antiplatelet therapy (SAPT) with aspirin was comparable to SAPT with P2Y12 inhibitor, with no treatment-by-subgroup interaction for major bleeding events (p-interaction = 0.27). In studies including patients presenting with MI, a trend of more frequent MI was noted in the short-DAPT arm (OR 1.25, 95% CI 0.98–1.59; p = 0.07; I2 = 0). In a sensitivity analysis comparing 3- and 12-month DAPT, the 3-month DAPT strategy was associated with a higher risk of ischemic stroke (OR 2.37, 95% CI 1.15–4.87; p = 0.02, I2 = 0%). Short-term DAPT after PCI in HBR patients was associated a reduction in major bleeding events and similar ischemic outcomes. However, a higher risk of ischemic stroke and MI at 1 year of follow-up was seen in some subsets.

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