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Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients

Authors
 Tullio Palmerini  ;  Diego Della Riva  ;  Umberto Benedetto  ;  Letizia Bacchi Reggiani  ;  Fausto Feres  ;  Alexandre Abizaid  ;  Martine Gilard  ;  Marie-Claude Morice  ;  Marco Valgimigli  ;  Myeong-Ki Hong  ;  Byeong-Keuk Kim  ;  Yangsoo Jang  ;  Hyo-Soo Kim  ;  Kyung Woo Park  ;  Antonio Colombo  ;  Alaide Chieffo  ;  Diego Sangiorgi  ;  Giuseppe Biondi-Zoccai  ;  Philippe Généreux  ;  Gianni D. Angelini  ;  Maria Pufulete  ;  Jonathon White  ;  Deepak L. Bhatt  ;  Gregg W. Stone 
Citation
 EUROPEAN HEART JOURNAL, Vol.38(14) : 1034-1043, 2017 
Journal Title
 EUROPEAN HEART JOURNAL 
ISSN
 0195-668X 
Issue Date
2017
MeSH
Acute Coronary Syndrome/mortality ; Acute Coronary Syndrome/therapy* ; Analysis of Variance ; Aspirin/administration & dosage ; Blood Vessel Prosthesis Implantation/methods ; Blood Vessel Prosthesis Implantation/mortality ; Coronary Artery Disease/mortality ; Coronary Artery Disease/therapy* ; Death, Sudden, Cardiac/epidemiology ; Drug Administration Schedule ; Drug Therapy, Combination ; Drug-Eluting Stents* ; Female ; Graft Occlusion, Vascular/etiology ; Hemorrhage/chemically induced ; Humans ; Male ; Middle Aged ; Myocardial Infarction/mortality ; Myocardial Revascularization/methods ; Myocardial Revascularization/mortality ; Platelet Aggregation Inhibitors/administration & dosage* ; Purinergic P2Y Receptor Antagonists/administration & dosage ; Randomized Controlled Trials as Topic ; Risk Assessment ; Stroke/mortality ; Ticlopidine/administration & dosage ; Ticlopidine/analogs & derivatives ; Treatment Outcome
Keywords
Drug-eluting stent ; Dual antiplatelet therapy ; Stent thrombosis
Abstract
AIM: We sought to determine whether the optimal 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 study outcome 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 MI or 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 MI or 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 the optimal duration of DAPT after DES in individual patients based on their relative ischaemic and bleeding risks.
Full Text
https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehw627
DOI
10.1093/eurheartj/ehw627.
Appears in Collections:
1. College of Medicine (의과대학) > Dept. of Internal Medicine (내과학교실) > 1. Journal Papers
Yonsei Authors
Kim, Byeong Keuk(김병극) ORCID logo https://orcid.org/0000-0003-2493-066X
Jang, Yang Soo(장양수) ORCID logo https://orcid.org/0000-0002-2169-3112
Hong, Myeong Ki(홍명기) ORCID logo https://orcid.org/0000-0002-2090-2031
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/154412
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