Risk-Benefit of 1-Year DAPT After DES Implantation in Patients Stratified by Bleeding and Ischemic Risk

Abstract

BACKGROUND Although a 1-year duration of dual antiplatelet therapy (DAPT) is used in many patients after drug eluting stent (DES) implantation, the evidence supporting this duration is uncertain. OBJECTIVES The authors investigated the risk-benefit profile of 1-year vs .6-month DAPT after DES using 2 novel scores to risk stratify bleeding and ischemic events. METHODS Ischemic and bleeding risk scores were generated from ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents), a multicenter, international, "all-comers" registry that enrolled 8,665 patients treated with DES. The risk-benefit profile of 1-year vs .6-month DAPT was then investigated across risk strata from an individual patient data pooled dataset of 7 randomized trials that enrolled 15,083 patients treated with DES. RESULTS In the derivation cohort, the ischemic score and the bleeding score had c-indexes of 0.76 and 0.66, respectively, and both were well calibrated. In the pooled dataset, no significant difference was apparent in any ischemic endpoint between 1-year and .6-month DAPT, regardless of the risk strata. In the overall dataset, there was no significant difference in the risk of clinically relevant bleeding between 1-year and .6-month DAPT; however, among 2,508 patients at increased risk of bleeding, 1-year compared with .6-month DAPT was associated with greater bleeding (HR: 2.80; 95% CI: 1.12-7.13) without a reduced risk of ischemic events in any risk strata, including those with acute coronary syndromes. These results were consistent in a network meta-analysis. CONCLUSIONS In the present large-scale study, compared with .6-month DAPT, a 1-year duration of DAPT was not associated with reduced adverse ischemic events in any risk strata (including acute coronary syndromes) but was associated with greater bleeding in patients at increased risk of bleeding. (J Am Coll Cardiol 2021;78:1968-1986) (c) 2021 by the American College of Cardiology Foundation.