Abstract:
Background: The optimal duration of dual antiplatelet (DAPT) after the implantation of drug-eluting stents (DES) remains uncertain, as the randomized controlled trials (RCTs) available were inadequate to detect a significant difference in reducing risk of major adverse cardiac events (MACE). The AHA/ACC guideline has recommended 12 months while European guideline suggested 6 months of DAPT.
Objectives: This meta-analysis aims to compare the efficacy and safety of four different durations of DAPT, from 3 months (VSDAPT), 6 months (SDAPT), 12 months (LDAPT) to ≥12 months (EDAPT), after the implantation of DES by performing an individual patient data pairwise and network meta-analysis.
Methods: Electronic databases such as The Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were used to identify relevant randomized controlled trials. Our primary endpoint was MACE (Major Adverse Cardiovascular Events), which was defined as all death, myocardial infarction, stroke and any revascularization. Safety outcome measured were major bleeding. Relative risk (RR) and 95% confidence interval (CI) were used to determine random-effect and fixed models. Surface area under the cumulative ranking (SUCRA) was also performed to identify the rank the durations by its efficacy.
Results: We identified 13 RCTs with a total of 30,901 participants. Compared to LDAPT, EDAPT significantly reduces the risk of myocardial infarction (RR: 0.55, 95% CI: 0.39 to 0.79) but increases the risk of major bleeding concurrently (RR: 1.72, 95% CI: 1.36 to 2.19). In summary, longer DAPT significantly reduces the risk of myocardial infarction (RR: 0.75, 95% CI: 0.62 to 0.91), stent thrombosis (RR: 0.61, 95% CI: 0.40 to 0.92), non-cardiovascular related death (RR: 1.31, 95% CI: 1.02 to 1.68) and MACE (RR: 0.90, 95% CI: 0.82 to 0.99) but similarly increases the risk of major bleeding (RR: 1.60, 95% CI: 1.31 to 1.97) when compared to shorter DAPT.
Conclusion: Compared with shorter DAPT, longer DAPT significantly reduces the risk of myocardial infarction, stent thrombosis, non-cardiovascular related death and MACE but comes with a price of a higher major bleeding rate. However, EDAPT was only seen to be beneficial in reducing risk of myocardial infarction. Thus, EDAPT may be favourable in patients with a higher risk of ischemic events and a lower risk of bleeding. Moreover, VSDAPT/SDAPT were non-inferior to LDAPT in any primary endpoint outcomes but also with an increased risk of major bleeding. Therefore, the portfolio of each individual should be taken into consideration during decision-making.
Keywords: Dual antiplatelet therapy, drug-eluting stents, network meta-analysis, aspirin, clopidogrel
