Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials

Abstract

Aims The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. The current study, using the totality of existing evidence, evaluated the impact of an abbreviated DAPT regimen in HBR patients. Methods and results A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated [i.e. very-short (1 month) or short (3 months)] with standard (≥6 months) DAPT in HBR patients without indication for oral anticoagulation. A total of 11 trials, including 9006 HBR patients, were included. Abbreviated DAPT reduced major or clinically relevant non-major bleeding [risk ratio (RR): 0.76, 95% confidence interval (CI): 0.61–0.94; I2 = 28%], major bleeding (RR: 0.80, 95% CI: 0.64–0.99, I2 = 0%), and cardiovascular mortality (RR: 0.79, 95% CI: 0.65–0.95, I2 = 0%) compared with standard DAPT. No difference in all-cause mortality, major adverse cardiovascular events, myocardial infarction, or stent thrombosis was observed. Results were consistent, irrespective of HBR definition and clinical presentation. Conclusion In HBR patients undergoing PCI, a 1- or 3-month abbreviated DAPT regimen was associated with lower bleeding and cardiovascular mortality, without increasing ischaemic events, compared with a ≥6-month DAPT regimen. Study registration PROSPERO registration number CRD42021284004

Editorial: Precision medicine for antithrombotic therapy in patients after percutaneous coronary interventions

“…These finding are in line with previous reports (4). Collectively, evidence from these studies support an intensified/prolonged antithrombotic regimen may be particularly useful in high-ischemic risk patients, particularly if not at high risk for bleeding (5).…”

Prognostic impact of peripheral artery disease in patients with and without high bleeding risk undergoing percutaneous coronary intervention

“…17,18 We demonstrated here that the ischemic/bleeding trade-off remains nearly unchanged when HBR patients have concomitant PAD, a strong predictor of ischemic complications. Effective bleeding avoidance strategies for HBR patients undergoing PCI include early discontinuation of aspirin or P2Y 12 inhibitor [19][20][21][22] as well as dual antiplatelet therapy (DAPT) de-escalation from a potent P2Y 12 inhibitor to Clopidogrel. 23,24 Whether these strategies are safe and effective in PAD patients needs to be determined in dedicated studies.…”

Thirty-Days versus Longer Duration of Dual Antiplatelet Treatment after Percutaneous Coronary Interventions with Newer Drug-Eluting Stents: A Systematic Review and Meta-Analysis

“…Thus, our findings could be applicable in both populations; nevertheless, the theoretical benefit would be greater in those with high or very high bleeding risk. Montalto et al showed that abbreviated DAPT is beneficial in patients under oral anticoagulation, while Costa et al supported that a 1- or 3-month DAPT regimen was related with reduced bleedings and cardiovascular mortality, without increasing ischemic events [ 40 , 41 ].…”