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Short-Term DAPT After DES in Patients With ACS
Quick Takes
- In patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT.
- However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE.
- Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.
Study Questions:
What is the efficacy and safety of different durations of dual antiplatelet therapy (DAPT) strategies in patients with acute coronary syndromes (ACS) using a Bayesian network meta-analysis?
Methods:
The investigators searched MEDLINE, Embase, Cochrane, and LILACS databases from inception to April 8, 2024. Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing percutaneous coronary intervention (PCI) were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT. This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a Bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA). The primary efficacy endpoint was major adverse cardiac and cerebrovascular events (MACCE); the primary safety endpoint was major bleeding.
Results:
A total of 15 RCTs randomizing 35,326 patients (mean [SD] age, 63.1 [11.1] years; 26,954 male [76.3%]; 11,339 ST-segment elevation myocardial infarction [STEMI] [32.1%]) with ACS were included. A total of 24,797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).
Conclusions:
The authors report that in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT.
Perspective:
This systematic review reports no difference between DAPT duration strategies in the incidence of MACCE, all-cause mortality, MI, stroke, stent thrombosis, or target-vessel revascularization. While a reduction in major bleeding was associated with 1 month of DAPT followed by P2Y12 inhibitor monotherapy as compared with conventional 12 months of DAPT; SUCRA analysis ranked 3 months of DAPT followed by P2Y12 inhibitors as the best for preventing MACCE and 1 month of DAPT followed by P2Y12 inhibitors as the best for preventing major bleeding. Similar results were found in patients with STEMI and NSTE-ACS. Because most patients receiving P2Y12 inhibitor monotherapy were on ticagrelor, the safety of stopping aspirin in those taking clopidogrel is unclear. These data provide insights to clinicians on optimal DAPT duration after PCI in patients with ACS.
Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Drug-Eluting Stents, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Agonists
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