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Bleeding-Related Deaths and DAPT Duration
Study Questions:
What is the association between bleeding, mortality, and duration of dual antiplatelet therapy (DAPT) in patients with drug-eluting stent (DES) implantation?
Methods:
The authors performed a meta-analysis of all randomized controlled trials (RCTs) comparing different DAPT durations after DES placement. Deaths were considered possibly bleeding-related if occurring within 1 year from the episode of bleeding.
Results:
The authors pooled individual patient data for six RCTs, and used aggregate data for a total of 12 studies. Patients with bleeding had significantly higher rates of mortality compared to those without (adjusted hazard ratio [HR], 6.93; 95% confidence interval [CI], 4.53-10.60; p < 0.0001), with the highest hazard concentrated in the first 30 days. Shorter DAPT was associated with lower rates of all-cause death compared with prolonged DAPT (HR, 0.85; 95% CI, 0.73-1.00; p = 0.05), which was driven by lower rates of bleeding-related deaths with shorter DAPT (HR, 0.65; 95% CI, 0.43-0.99; p = 0.04). There was no difference in mortality unrelated to bleeding between the two groups.
Conclusions:
Shorter DAPT was associated with a lower risk of mortality in patients treated with DES, and this appears to be driven by a lower risk of bleeding and bleeding-related mortality.
Perspective:
The optimal duration of DAPT continues to be debated despite a large body of randomized data. The key finding of this study is intuitive and biologically plausible, and supports shorter duration of DAPT in most patients treated with contemporary DES, with prolonged DAPT reserved for those at high risk of thrombotic events.
Keywords: Drug-Eluting Stents, Hemorrhage, Mortality, Platelet Aggregation Inhibitors, Randomized Controlled Trials as Topic, Risk Assessment, Stents, Thrombosis
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