Duration of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndrome Treated With New Generation Stents: A Meta-Analysis of Randomized Controlled Trials

Abstract

Background and Objective: The optimum duration of dual antiplatelet therapy (DAPT) remains uncertain in patients with acute coronary syndrome treated with new generation stents. This meta-analysis was performed to investigate ischemia and bleeding outcomes with different DAPT strategies.Methods: PubMed, Embase, Cochrane and Web of science from inception to May 27, 2020, were systematically searched. Randomized controlled trials were included to compare short-term (6 months or less) with standard (12 months) DAPT in patients with acute coronary syndrome treated with new generation stents. The primary endpoints were myocardial infarction, definite or probable stent thrombosis and major bleeding. The secondary endpoints included all-cause death, cardiovascular death, stroke, target vessel revascularization and net adverse clinical events. Random effect model and fixed effect model were used to calculate the odds ratio (OR) and 95% confidence interval (CI) of each endpoint.Results: Four randomized controlled trials and seven subgroup analyses of larger randomized controlled trials, including a total of 21,344 patients with acute coronary syndrome, met our inclusion criteria. The shorter DAPT was associated with significantly lower major bleeding compared with the standard DAPT (OR 0.71, 95% CI 0.56–0.90, P = 0.005, I2 = 25%), while without increasing the risk of myocardial infarction (OR 1.18, 0.88–1.58, P = 0.28, I2 = 20%), definite or probable stent thrombosis (OR 1.60, 0.98–2.59, P = 0.06, I2 = 0%). No significantly difference was observed in the risk of all-cause death (OR 0.96, 0.72–1.27, P = 0.76, I2 = 2%), cardiovascular death (OR 0.91, 0.62–1.33, P = 0.62, I2 = 0%), stroke (OR 0.84, 0.54–1.30, P = 0.43, I2 = 0%), target vessel revascularization (OR 1.14, 0.84–1.55, P = 0.41, I2 = 8%), and net adverse clinical events (OR 0.93, 0.80–1.07, P = 0.3, I2 = 18%) between the two groups.Conclusions: In patients with acute coronary syndrome treated with new generation stents, the shorter DAPT leads to a marked reduction in the risk of major bleeding compared with the standard DAPT. This benefit is achieved without increasing the risk of mortality or ischemic outcomes. The study protocol was registered in PROSPERO (CRD42020189871).

Three versus 12‐month dual antiplatelet therapy duration in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta‐analysis of randomized controlled trials

“…The risk of major bleeding, more than ischemic risk, often determines clinical decision-making regarding optimal DAPT duration. 7 Multiple previous randomized controlled trials (RCTs) and meta-analyses comparing different DAPT durations in patients with ACS [8][9][10][11][12][13][14] have suggested that abbreviated DAPT followed by antiplatelet monotherapy might be efficacious in not increasing ischemic events and minimizing bleeding risk [8][9][10][11][12] However, the optimal DAPT duration to achieve this clinical equipoise is uncertain. We have previously reported that in select patients with ACS, 6-month DAPT may be a reasonable option compared to 12-month DAPT.…”

Dual antiplatelet therapy after percutaneous coronary intervention in patients at high bleeding risk: A systematic review and meta-analysis

“…In the context of the increased risk of ST caused by delayed endothelialization, hypersensitivity reaction, and inflammation of first-generation DES [ 21 ], new-generation DES came into being. For the latter, the application of newer antiproliferative drugs with new polymers resulted in less inflammation [ 22 ], and the development of the cobalt-chromium platform implemented a thin stent structure to improve flexibility and deliver-ability [ 23 , 24 ]. A recent meta-analysis showed that the risk for ST was higher with first-generation DES compared with new-generation DES when short-term DAPT was compared to long-term DAPT (p for interaction = 0.008) [ 25 ].…”

P2Y12 Antagonists in Cardiovascular Disease—Finding the Best Balance Between Preventing Ischemic Events and Causing Bleeding

“…The SECURITY, ISAR_SAFE, I-LOVE-IT 2, and SMART-DATE trials also suggested that 6 months of DAPT was not-inferior to 12 months ( 88 – 91 ). A meta-analysis of trials evaluating shorter durations of DAPT identified a reduced risk of major bleeding overall without an increase in ischemic events and death ( 92 ). However, as mentioned in the individual trials, the sample sizes are likely underpowered to evaluate ischemic outcomes.…”