Shorter Dual Antiplatelet Therapy Reduces Bleeding Risk Without Increasing MACCE in ACS Patients Undergoing PCI: JAMA
Reducing the duration of dual antiplatelet therapy (DAPT) to 1 month with subsequent monotherapy with a P2Y12 inhibitor was associated with an important reduction of major bleeding in acute coronary syndrome (ACS) patients who were treated with percutaneous coronary intervention (PCI), according to researchers. A study was conducted by Carvalho and colleagues which was recently published in JAMA Cardiology.
The study carried out systematic review and network meta-analysis according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis. It evaluated the effectiveness and safety of various DAPT durations in patients with ACS treated with PCI. The center of comparison was among short-term DAPT strategies, including DAPT for 1 month, DAPT for 3 months, DAPT for 6 months plus P2Y12 inhibitors or aspirin with a conventional 12-month DAPT strategy. Major endpoints included major adverse cardiac and cerebrovascular events (MACCE), used as an endpoint measure of efficacy, and major bleeding, used as a safety endpoint.
Four major databases-MEDLINE, Embase, Cochrane, and LILACS-were searched from inception through April 2024. RCTs were analyzed with a focus on comparing DAPT strategies in patients with ACS undergoing PCI. A total of 15 RCTs, comprising 35,326 participants, were included and provided sufficient evidence for powerful Bayesian network meta-analysis.
• The research sourced data from 35,326 patients at the ACS, with a mean age of 63.1 years and a standard deviation of 11.1 years. Of all patients studied, 76.3% were male, and 32.1% had STEMI diagnosis.
• The majority of patients received one of the potent P2Y12 inhibitors-ticagrelor or prasugrel-amounting to 70.2%, or 24,797 patients.
• Bleeding risk within one month of DAPT followed by P2Y12 inhibitor monotherapy was significantly lower than after 12 months of DAPT (RR, 0.47; 95% CrI, 0.26-0.74).
• The incidence of MACCE was not significantly different between the strategy of 1-month DAPT and 12-month strategy (RR, 1.00; 95% CrI, 0.70-1.41). Credible intervals were quite wide.
• The SUCRA rankings showed that the strongest strategy to reduce major bleeding was to administer 1 month of DAPT followed by monotherapy on P2Y12 inhibitors. For MACCE, 3 months of DAPT followed by monotherapy on P2Y12 inhibitors were ranked as the best (RR, 0.85; 95% CrI, 0.56-1.21).
In ACS patients treated with PCI and a drug-eluting stent, 1 month of DAPT plus P2Y12 inhibitor monotherapy significantly reduced major bleeding at the expense of adding no further risk of MACCE. Further research will be needed to evaluate the safety of discontinuing aspirin in patients on clopidogrel as well as delineate long-term outcomes with these DAPT strategies.
Reference:
Carvalho PEP, Gewehr DM, Nascimento BR, et al. Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. JAMA Cardiol. Published online October 09, 2024. doi:10.1001/jamacardio.2024.3216
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