Shorter vs. Longer Duration of Antiplatelet Therapy After PCI

Dec 21, 2020
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Authors:
Giacoppo D, Matsada Y, Fovino LN, et al.
Citation:
Short Dual Antiplatelet Therapy Followed by P2Y12 Inhibitor Monotherapy vs. Prolonged Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Eur Heart J 2020;Dec 7:[Epub ahead of print].
Summary By:
Bina Ahmed, MD, FACC

Quick Takes

  • Conservative antiplatelet therapy (3 months of DAPT followed by single antiplatelet therapy [SAPT] for 12 months) is associated with a lower rate of major bleeding without increased ischemic risk.
  • Both aspirin and P2Y12 inhibitor as SAPT agents conferred bleeding advantage.
  • Several questions remain about the generalizability of the findings especially since bleeding and ischemic risk can vary based on patient risk. An individual patient-level analysis from randomized controlled trials may be necessary to gain further insight.
 

Study Questions:

How does short-duration dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy (SAPT) with a P2Y12 receptor inhibitor compare with prolonged DAPT (12 months) among patient undergoing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES)?

Methods:

A meta-analysis was conducted of clinical trials comparing <3-month DAPT followed by SAPT versus 12-month DAPT after second-generation DES PCI. The primary and co-primary outcomes of interest were major bleeding and stent thrombosis 1 year after randomization. Summary hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by fixed-effect and random-effects models. Multiple sensitivity analyses including random-effects models (95% CI adjustment) were applied. A sensitivity analysis comparing trials using P2Y12 inhibitor SAPT with those using aspirin SAPT was performed.

Results:

A total of five randomized clinical trials (n = 32,145 patients) were available. Major bleeding was significantly lower in the patients assigned to short DAPT followed by P2Y12 inhibitor SAPT compared with those assigned to 12-month DAPT (random-effects model: HR, 0.63; 95% CI, 0.45–0.86). No significant differences between groups were observed in terms of stent thrombosis (random-effects model: HR, 1.19; 95% CI ,0.86–1.65) and the secondary endpoints of all-cause death (random-effects model: HR, 0.85; 95% CI, 0.70–1.03), myocardial infarction (random-effects model: HR, 1.05; 95% CI, 0.89–1.23), and stroke (random-effects model: HR, 1.08; 95% CI, 0.68–1.74). Sensitivity analyses showed overall consistent results. By comparing trials testing <3 months of DAPT followed by P2Y12 inhibitor SAPT versus 12 months of DAPT with trials testing <3 months of DAPT followed by aspirin SAPT versus 12 months of DAPT, there was no treatment by subgroup interaction for each endpoint. By combining all these trials, regardless of the type of SAPT, short DAPT was associated with lower major bleeding (random-effects model: HR, 0.63; 95% CI, 0.48–0.83), and no differences in stent thrombosis, all-cause death, myocardial infarction, and stroke were observed between regimens.

Conclusions:

After second-generation DES implantation, 1–3 months of DAPT followed by P2Y12 inhibitor SAPT is associated with lower major bleeding and similar stent thrombosis, all-cause death, myocardial infarction, and stroke compared with prolonged DAPT. Whether P2Y12 inhibitor SAPT is preferable to aspirin SAPT needs further investigation.

Perspective:

Findings from this meta-analysis of a heterogenous group of randomized controlled trials suggest that conservative antiplatelet therapy (3 months of DAPT followed by SAPT for 12 months) is associated with a lower rate of major bleeding compared to prolonged DAPT and does not come with increased ischemic risk among patients receiving second-generation DES. Several questions remain about the generalizability of the findings, especially since bleeding and ischemic risk can vary based on patient risk. An individual patient-level analysis from randomized controlled trials may be necessary to gain further insight.

Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention

Keywords: Aspirin, Drug-Eluting Stents, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Stents, Stroke, Thrombosis, Vascular Diseases


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