Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients
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- 20 January 2017
- journal article
- research article
- Published by Oxford University Press (OUP) in European Heart Journal
- Vol. 38 (14), 1034-1043
- https://doi.org/10.1093/eurheartj/ehw627
Abstract
We sought to determine whether the optimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary study outcome was the 1-year composite risk of myocardial infarction (MI) or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MI or ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98–2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65–1.35; P = 0.71; Pinteraction = 0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MI or ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify the optimal duration of DAPT after DES in individual patients based on their relative ischaemic and bleeding risks.Keywords
This publication has 27 references indexed in Scilit:
- 2014 ESC/EACTS Guidelines on myocardial revascularizationEuropean Heart Journal, 2014
- Three vs Twelve Months of Dual Antiplatelet Therapy After Zotarolimus-Eluting StentsJAMA, 2013
- A New Strategy for Discontinuation of Dual Antiplatelet TherapyJournal of the American College of Cardiology, 2012
- Short- Versus Long-Term Duration of Dual-Antiplatelet Therapy After Coronary StentingCirculation, 2012
- Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysisThe Lancet, 2012
- Six-Month Versus 12-Month Dual Antiplatelet Therapy After Implantation of Drug-Eluting StentsCirculation, 2012
- A Risk Score to Predict Bleeding in Patients With Acute Coronary SyndromesJournal of the American College of Cardiology, 2010
- The Risk of Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Bare-Metal and Drug-Eluting StentsJACC: Cardiovascular Interventions, 2009
- Long-term clopidogrel therapy after percutaneous coronary intervention in PCI-CURE and CREDO: the “Emperor's New Clothes” revisitedEuropean Heart Journal, 2004
- Early and Late Effects of Clopidogrel in Patients With Acute Coronary SyndromesCirculation, 2003