TY - JOUR
T1 - Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes
T2 - An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients
AU - Palmerini, Tullio
AU - Della Riva, Diego
AU - Benedetto, Umberto
AU - Reggiani, Bletizia Bacchi
AU - Feres, Fausto
AU - Abizaid, Alexandre
AU - Gilard, Martine
AU - Morice, Marie Claude
AU - Valgimigli, Marco
AU - Hong, Myeong Ki
AU - Kim, Byeong Keuk
AU - Jang, Yangsoo
AU - Kim, Hyo Soo
AU - Park, Kyung Woo
AU - Colombo, Antonio
AU - Chieffo, Alaide
AU - Sangiorgi, Diego
AU - Biondi-Zoccai, Giuseppe
AU - Généreux, Philippe
AU - Angelini, Gianni D.
AU - Pufulete, Maria
AU - White, Jonathon
AU - Bhatt, Deepak L.
AU - Stone, Gregg W.
PY - 2017
Y1 - 2017
N2 - Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.
AB - Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.
KW - Drug-eluting stent
KW - Dual antiplatelet therapy
KW - Stent thrombosis
UR - http://www.scopus.com/inward/record.url?scp=85015053064&partnerID=8YFLogxK
U2 - 10.1093/eurheartj/ehw627
DO - 10.1093/eurheartj/ehw627
M3 - Article
C2 - 28110296
AN - SCOPUS:85015053064
SN - 0195-668X
VL - 38
SP - 1034
EP - 1043
JO - European Heart Journal
JF - European Heart Journal
IS - 14
ER -