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. 2024 Dec 1;9(12):1094-1105.
doi: 10.1001/jamacardio.2024.3216.

Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis

Pedro E P Carvalho  1 , Douglas M Gewehr  2 , Bruno R Nascimento  3   4 , Lara Melo  5 , Giullia Burkhardt  6 , André Rivera  7 , Marcelo A P Braga  8 , Patricia O Guimarães  9 , Roxana Mehran  10   11 , Stephan Windecker  12 , Marco Valgimigli  13   14   15 , Dominick J Angiolillo  16 , Deepak L Bhatt  10 , Yader Sandoval  1 , Shao-Liang Chen  17 , Gregg W Stone  10 , Renato D Lopes  18
Affiliations

Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis

Pedro E P Carvalho et al. JAMA Cardiol. .

Abstract

Importance: The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.

Objectives: To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis.

Data sources: MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.

Study selection: Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT.

Data extraction and synthesis: This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).

Main outcomes and measures: The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.

Results: A total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).

Conclusion and relevance: Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Mehran reported receiving grants from Abbott, Abiomed, Affluent Medical, Alleviant Medical, Amgen, AM-Pharma, Arena, AstraZeneca, AtriCure Inc, Biosensors, Biotronik, Boston Scientific, Bristol Myers Squibb, CardiaWave, CeloNova, CERC, Chiesi, Concept Medical, Cytosorbents, Daiichi Sankyo, Duke, Element Science, Essential Medical, Faraday, Humacyte, Idorsia, Janssen, MedAlliance, Medscape, Mediasphere, Medtelligence, Medtronic, MJH Healthcare, Novartis, OrbusNeich, Penumbra, PhaseBio, Philips, Pi-Cardia, PLx Pharma, Population Health Research Institute, Protembis, ReCor Medical Inc, RenalPro, RM Global, Sanofi, Shockwave, Vivasure, and Zoll; personal fees from Affluent Medical, Cardiovascular Research Foundation (CRF), Cordis, Daiichi Sankyo Brasil, E.R. Squibb & Sons, Esperion Science/Innovative Biopharma, Europa Group/Boston Scientific, Gaffney Events, Educational Trust, Ionis Pharmaceuticals, MedCon International, Novartis, Novo Nordisk, PeerView Institute for Medical Education, TERUMO Europe N.V., Vectura, VoxMedia, IQVIA, Radcliffe, TARSUS Cardiology, WebMD, Elixir Medical, and STEL; scientific advisory board fees from the American Medical Association; and serving as a committee member for SCAI and the American College of Cardiology outside the submitted work. Dr Windecker reported receiving grants from Abbott, Abiomed, Amgen, AstraZeneca, Bayer, B. Braun Medical, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardinal Health, CardioValve, Cordis Medical, Corflow Therapeutics, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Farapulse Inc, Fumedica, Guerbet, Idorsia, Inari Medical, InfraRedx, Janssen-Cilag, Johnson & Johnson, Medalliance, Medicure, Medtronic, Merck Sharp & Dohm, Miracor Medical, Novartis, Novo Nordisk, Organon, OrPha Suisse, Pharming Tech, Pfizer, Polares, Regeneron, Sanofi-Aventis, Servier, Sinomed, Terumo, Vifor, and V-Wave during the conduct of the study; serving as advisory board member and/or member of the steering/executive group of trials funded by Abbott, Abiomed, Amgen, Astra Zeneca, Bayer, Boston Scientific, Biotronik, Bristol Myers Squibb, Edwards Lifesciences, MedAlliance, Medtronic, Novartis, Polares, Recardio, Sinomed, Terumo, and V-Wave with payments to the institution but no personal payments; serving as member of the steering/executive committee group of several investigator-initiated trials that receive funding by industry without impact on his personal remuneration; and serving as vice president of the European Society of Cardiology and associate editor of JACC: Cardiovascular Interventions. Dr Angiolillo reported receiving consulting fees or honoraria from Abbott, Amgen, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, CSL Behring, Daiichi-Sankyo, Eli Lilly, Faraday, Haemonetics, Janssen, Merck, Novartis, PhaseBio, PLx Pharma, Pfizer, and Sanofi and grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Faraday, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co, Merck, Novartis, and the Scott R. MacKenzie Foundation. Dr Bhatt reported receiving grants from Amarin, Abbott, Amgen, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, Boston Scientific, Eisai, Ethicon, Idorsia, SynapticIronwood, Lilly, Medtronic, Merck, Regeneron, Roche, Sanofi Aventis, The Medicines Company, Pfizer, PhaseBio, Forest Laboratories, Ischemix, Novo Nordisk, Fractyl, Cereno Scientific, Afimmune, Ferring Pharmaceuticals, Lexicon, Contego Medical, CellProthera and PLx Pharma; participating in an unfunded research collaboration with FlowCo and Takeda; receiving advisory board frees from PLx Pharma, Medscape Cardiology, and Regado Biosciences; receiving committee fees from Duke Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; serving as senior associate editor for the American College of Cardiology Clinical Trials and News, ACC.org; serving as chair of the Accreditation Oversight Committee and trustee and chair of ACTION Registry Steering Committee; receiving travel fees from Belvoir Publications, WebMD, and Elsevier; serving on the board of directors for Boston VA Research Institute and the Society for Cardiovascular Patient Care Board of Directors; serving as the inaugural chair on the American Heart Association Quality Oversight Committee; serving as deputy editor for Clinical Cardiology; receiving nonfinancial support from HMP Global; receiving personal fees from Harvard Clinical Research Institute (now Baim Institute for Clinical Research) and the Journal of the American College of Cardiology; serving as VA Chair, VA Cardiovascular Assessment, Reporting and Tracking System (CART) Program, Research and Publications Committee; serving as site coinvestigator for St Jude Medical (Now Abbott) and Biotronik; receiving personal fees from Cleveland Clinic, Bayer, Medtelligence/ReachMD, CSL Behring, MJH Life Sciences, Level Ex, Mount Sinai School of Medicine; serving as site coinvestigator for Svelte Site; receiving personal fees from TobeSoft Board of Directors, Boehringer Ingelheim Executive Steering Committee; receiving editorial support services limited to collation of coauthor comments and formatting; receiving advisory/consulting fees from K2P, Canadian Medical and Surgical Knowledge Translation Research Group, Arnold and Porter Law Firm, Piper Sandler, Cowen and Company, DRS.LINQ, Assistance Publique-Hôpitaux de Paris, Rutgers University, Wiley, AngioWave, Endotronix, Oakstone, High Enroll; Bristol Myers Squibb, SpectraWAVE, Broadview Ventures, McKinsey CV, Hims, CSL Behring, American Heart Association NYC, SFJ, Youngene, and GlaxoSmithKline; receiving grants from Cleerly, Alnylam, Otsuka, MyoKardia/BMS, Owkin, HLS Therapeutics, Janssen, 89Bio, Garmin, Novartis, NirvaMed, CinCor, Youngene, Faraday, Javelin, Reid Hoffman Foundation, Moderna, Beren, Aker Biomarine, Recardio, Acesion Pharma; serving as site coinvestigator for Philips; and having a patent for sotagliflozin pending. Dr Sandoval reported receiving advisory board/committee/speaker/consulting fees from Abbott Diagnostics, Roche Diagnostics, GE Healthcare, Philips, Zoll, and JACC Advances editorial board and having a patent (#20210401347) issued for machine learning models for ECG-based troponin level detection. Dr Stone reported receiving speaker/committee/consulting/equity fees from Medtronic, Pulnovo, Infraredx, Abiomed, Amgen, Boehringer Ingelheim, Abbott, Daiichi Sankyo, Ablative Solutions, CorFlow, Cardiomech, Robocath, Miracor, Vectorious, Abiomed, Valfix, Apollo Therapeutics, Elucid Bio, Cardiac Success, TherOx, HeartFlow, Neovasc, Ancora, Occlutech, Impulse Dynamics, Adona Medical, Millennia Biopharma, Oxitope, HighLife, Elixir, Remote Cardiac Enablement, Aria, Cardiac Success, Ancora, Cagent, Applied Therapeutics, Biostar, SpectraWave, Orchestra Biomed, Aria, Valfix, and Xenter; and grants from Shockwave, Abbott, Abiomed, Bioventrix, Cardiovascular Systems Inc, Phillips, Biosense-Webster, Vascular Dynamics, Pulnovo, V-wave outside the submitted work. Dr Lopes reported receiving grants from Amgen, Glaxo Smith Kline, Medtronic, Pfizer, and Sanofi and speaker/consulting fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Bristol Myers Squibb, Daiichi Sankyo, Novo Nordisk, and Pfizer outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Primary End Points Network Plots and League Tables
Nodes represent dual antiplatelet therapy (DAPT) strategies and edges represent direct comparisons in included trials. Node size correlates with patients assigned, and edge thickness correlates with the number of direct comparisons.
Figure 2.
Figure 2.. Primary End Points League Tables
A and C, Risk ratios (RRs) and 95% credible intervals (CrIs) were plotted comparing 12 months of dual antiplatelet therapy (DAPT), the reference treatment, with each short-term DAPT strategy. B and D, DAPT strategies are listed alphabetically. Data are RRs with 95% CrI. Comparisons should be read from left to right comparing column-defining treatment with row-defining treatment. RRs lower than 1 favor the column-defining treatment compared with the row-defining treatment. MACCE indicates major adverse cardiac and cerebrovascular events; RR, risk ratio. aIndicates significant results.
Figure 3.
Figure 3.. Secondary End Points
Risk ratios (RRs) and 95% credible intervals (CrIs) compared with 12 months of dual antiplatelet therapy (DAPT), the reference, were plotted for all secondary outcomes.
See this image and copyright information in PMC

References

    1. Byrne RA, Rossello X, Coughlan JJ, et al. ; ESC Scientific Document Group . 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44(38):3720-3826. doi: 10.1093/eurheartj/ehad191 - DOI - PubMed
    1. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022;145(3):e4-e17. doi: 10.1161/CIR.0000000000001039 - DOI - PubMed
    1. Mauri L, Kereiakes DJ, Yeh RW, et al. ; DAPT Study Investigators . Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med. 2014;371(23):2155-2166. doi: 10.1056/NEJMoa1409312 - DOI - PMC - PubMed
    1. Rodriguez F, Harrington RA. Management of antithrombotic therapy after acute coronary syndromes. N Engl J Med. 2021;384(5):452-460. doi: 10.1056/NEJMra1607714 - DOI - PMC - PubMed
    1. Capodanno D, Bhatt DL, Gibson CM, et al. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol. 2022;19(2):117-132. doi: 10.1038/s41569-021-00598-1 - DOI - PubMed

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