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Bleeding-related deaths in patients treated with shorter versus longer dual antiplatelet therapy after drug-eluting stent implantation: aggregate and patient-level meta-analysis of randomized trials

Authors
 Tullio Palmerini  ;  Letizia Bacchi Reggiani  ;  Diego Della Riva  ;  Mattia Romanello  ;  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  ;  Jung-Min Ahn  ;  Seung-Jung Park  ;  Stefanie Schüpke  ;  Adnan Kastrati  ;  Gilles Montalescot  ;  Philippe Gabriel Steg  ;  Abdourahmane Diallo  ;  Eric Vicaut  ;  Gerard Helft  ;  Giuseppe Biondi-Zoccai  ;  Bo Xu  ;  Yaling Han  ;  Philippe Genereux  ;  Deepak L. Bhatt  ;  Gregg W. Stone 
Citation
 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, Vol.69(16) : 2011-2022, 2017 
Journal Title
 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 
ISSN
 0735-1097 
Issue Date
2017
Keywords
drug-eluting stent ; dual antiplatelet therapy ; mortality
Abstract
BACKGROUND Although some randomized controlled trials (RCTs) and meta-analyses have suggested that prolonged dual-antiplatelet therapy (DAPT) may be associated with increased mortality, the mechanistic underpinnings of this association remain unclear. OBJECTIVES The aim of this study was to analyze the associations among bleeding, mortality, and DAPT duration after drug-eluting stent implantation in a meta-analysis of RCTs. METHODS RCTs comparing different DAPT durations after drug-eluting stent placement were sought through the MEDLINE, Embase, and Cochrane databases and the proceedings of international meetings. Deaths were considered possibly bleeding related if occurring within 1 year of the episodes of bleeding. Primary analysis was by intention-totreat. Secondary analysis was performed in a modified intention-to-treat population in which events occurring when all patients were on DAPT were excluded. RESULTS Individual patient data were obtained for 6 RCTs, and aggregate data were available for 12 RCTs. Patients with bleeding had significantly higher rates of mortality compared with those without, and in a time-adjusted multivariate analysis, bleeding was an independent predictor of mortality occurring within 1 year of the bleeding episode (hazard ratio: 6.93; 95% confidence interval: 4.53 to 10.60; p < 0.0001). Shorter DAPT was associated with lower rates of all-cause death compared with longer DAPT (hazard ratio: 0.85; 95% confidence interval: 0.73 to 1.00; p ¼ 0.05), which was driven by lower rates of bleeding-related deaths with shorter DAPT compared with prolonged DAPT (hazard ratio: 0.65; 95% confidence interval: 0.43 to 0.99; p ¼ 0.04). Mortality unrelated to bleeding was comparable between the 2 groups. Similar results were apparent in the modified intention-to-treat population. CONCLUSIONS Bleeding was strongly associated with the occurrence of mortality within 1 year after the bleeding event. Shorter compared with longer DAPT was associated with lower risk for bleeding-related death, a finding that may underlie the lower all-cause mortality with shorter DAPT in the RCTs of different DAPT durations after DES. (J Am Coll Cardiol 2017;69:2011–22)
Full Text
https://www.sciencedirect.com/science/article/pii/S0735109717306964
DOI
10.1016/j.jacc.2017.02.029
Appears in Collections:
1. College of Medicine (의과대학) > Dept. of Internal Medicine (내과학교실) > 1. Journal Papers
Yonsei Authors
Hong, Myeong Ki(홍명기) ORCID logo https://orcid.org/0000-0002-2090-2031
URI
https://ir.ymlib.yonsei.ac.kr/handle/22282913/165835
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