Duration of Dual Antiplatelet Therapy After DES | Journal Scan

Mar 31, 2015
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Authors:
Giustino G, Baber U, Sartori S, et al.
Citation:
Duration of Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Coll Cardiol 2015;65:1298-1310.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is the efficacy and safety of shorter dual antiplatelet therapy (S-DAPT) versus longer DAPT (L-DAPT) after drug-eluting stent (DES) implantation, with particular focus on the risk of stent thrombosis (ST) with the use of current (second-generation) DES?

Methods:

The investigators included randomized controlled trials (RCTs), which tested different durations of DAPT after DES implantation: S-DAPT was defined as the per-protocol minimum duration of DAPT after the procedure, and L-DAPT was defined as the per-protocol period of more prolonged DAPT. Primary efficacy and safety outcomes were definite/probable ST and clinically significant bleeding (CSB), respectively. The authors calculated ST and CSB incidence rates per 100 person-years within each exposure group (S-DAPT and L-DAPT).

Results:

Ten RCTs (n = 32,135) were included. Compared with L-DAPT, S-DAPT had an overall higher rate of ST (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.26-2.32; p = 0.001). The effect on ST of S-DAPT was attenuated with use of second-generation DES (OR, 1.54; 95% CI, 0.96-2.47) compared with use of first-generation DES (OR, 3.94; 95% CI, 2.20-7.05; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of CSB (OR, 0.63; 95% CI, 0.52-0.75; p < 0.001). Finally, a numerically lower all-cause mortality was observed with S-DAPT (OR, 0.87; 95% CI, 0.74-1.01; p = 0.073), without statistical significance.

Conclusions:

The authors concluded that S-DAPT had overall lower rates of bleeding yet higher rates of ST compared with L-DAPT, and the latter effect was significantly attenuated with use of second-generation DES.

Perspective:

This study reports that S-DAPT was associated with significantly higher definite or probable ST rates compared with L-DAPT, but the magnitude of the effect of S-DAPT on ST was significantly attenuated with the use of second-generation DES. It should be noted that the thrombotic benefit of L-DAPT came at the cost of a higher risk of bleeding and numerically higher all-cause mortality. The results of this and other contemporary analyses suggest that the risk-benefit ratio of optimal DAPT duration may differ for each patient and should be carefully individualized considering both ischemic and bleeding risks.

Keywords: Drug-Eluting Stents, Stents, Thrombosis, Risk, Risk Assessment, Incidence


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