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Short Duration of DAPT vs. De-Escalation After PCI for ACS
Quick Takes
- Short DAPT and de-escalation carried a similar risk for death and cardiovascular death after PCI for ACS.
- Whereas short DAPT significantly reduced the risk for major bleeding and increased the risk for net adverse cardiovascular events (NACE), de-escalation significantly reduced the risk for NACE, but increased the risk for major bleeding.
- These data support personalized treatment decisions regarding short DAPT and de-escalation on the basis of treatment objectives and the balance between the risks for thrombosis and bleeding.
Study Questions:
What are the relative merits of short dual antiplatelet therapy (DAPT) and de-escalation for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI)?
Methods:
The investigators identified randomized trials of DAPT modulation strategies in patients with ACS undergoing PCI. All-cause death was the primary outcome. Secondary outcomes included net adverse cardiovascular events (NACE), major adverse cardiovascular events, and their components. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on the basis of posterior probability. Sensitivity analyses were performed to explore sources of heterogeneity.
Results:
Twenty-nine studies encompassing 50,602 patients were included. The transitivity assumption was fulfilled. In the frequentist indirect comparison, the risk ratio (RR) for all-cause death was 0.98 (95% confidence interval [CI], 0.68-1.43). De-escalation reduced the risk for NACE (RR, 0.87; 95% CI, 0.70-0.94) and increased major bleeding (RR, 1.54; 95% CI, 1.07-2.21). These results were consistent in the Bayesian meta-analysis. De-escalation displayed a >95% probability to rank first for NACE, myocardial infarction, stroke, stent thrombosis, and minor bleeding, while short DAPT ranked first for major bleeding. These findings were consistent in node-split and multiple sensitivity analyses.
Conclusions:
The authors concluded that in patients with ACS undergoing PCI, there was no difference in all-cause death between short DAPT and de-escalation.
Perspective:
This indirect comparison of short DAPT and de-escalation study reports that short DAPT and de-escalation carried a similar risk for death and cardiovascular death after PCI for ACS. Whereas short DAPT significantly reduced the risk for major bleeding and increased the risk for NACE, de-escalation significantly reduced the risk for NACE, but increased the risk for major bleeding. In the absence of direct randomized comparisons, and this indirect comparison suggesting equipoise of short DAPT and de-escalation strategies, these data allow personalized treatment decisions on the basis of treatment objectives and the balance between the risks for thrombosis and bleeding.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Hemorrhage, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Secondary Prevention, Stents, Stroke, Thrombosis, Vascular Diseases
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