DAPT de-escalation, short-term DAPT, best strategies for patients with acute coronary syndromes
USA: A recent network meta-analysis published in AHA Circulation Cardiovascular Interventions by Kuno T and colleagues has shed light on the optimal dual antiplatelet therapy (DAPT) strategy for patients with acute coronary syndrome (ACS). The study suggests that "unguided" de-escalation and a short course of DAPT followed by P2Y12 inhibitor monotherapy may be associated with the lowest risks of major adverse cardiovascular events (MACE) and major or minor bleeding, respectively.
The research aimed to explore various DAPT strategies and their outcomes in ACS patients, considering factors like genotyping and platelet function testing. Current guidelines in the US and Europe recommend different DAPT approaches for high-risk patients, but consensus on the best strategy remains elusive.
A comprehensive meta-analysis of 32 randomized controlled trials, involving a total of 103,497 patients, has provided essential insights into the most effective treatment strategies for individuals with acute coronary syndrome (ACS). The study examined various dual antiplatelet therapy (DAPT) approaches, offering critical guidance for optimizing patient care in ACS cases.
Key Findings:
Comparable Efficacy: The analysis found no significant differences in efficacy among short-term DAPT, unguided de-escalation, and guided selection strategies.
All three approaches performed similarly in preventing major adverse cardiovascular events (MACE), which include cardiovascular death, myocardial infarction (MI), or stroke.
However, unguided de-escalation stood out by significantly reducing the risk of MACE when compared to the standard DAPT regimens involving clopidogrel or ticagrelor.
The hazard ratios (HR) for unguided de-escalation versus standard DAPT were 0.67 (95% confidence interval [CI]: 0.49–0.93) and 0.68 (95% CI: 0.50–0.93) for clopidogrel and ticagrelor, respectively.
Enhanced Safety: In terms of safety and minimizing bleeding risks, two strategies demonstrated distinct advantages.
Both short-term DAPT followed by a P2Y12 inhibitor and unguided de-escalation were associated with significantly reduced risks of major or minor bleeding compared to other strategies, including guided selection.
Moreover, short-term DAPT followed by a P2Y12 inhibitor substantially lowered the risk of major bleeding and all-cause death when compared to standard or extended DAPT.
For instance, compared to DAPT with clopidogrel, the HRs for major bleeding were 0.64 (95% CI: 0.42–0.97) for short-term DAPT and 0.60 (95% CI: 0.44–0.82) for extended DAPT.
Customised Approaches: The study emphasizes the importance of tailoring treatment strategies based on individual patient profiles, considering both bleeding and ischemic risk factors.
In conclusion, tailoring DAPT for ACS patients based on individual risk profiles appears to be a promising strategy. However, further research is needed to establish the best approach, especially for high-risk patients who may benefit from specific de-escalation strategies that minimize bleeding while maintaining protection against MACE.
Reference:
Kuno T, Watanabe A, Shoji S, et al. Short-term DAPT and DAPT de-escalation strategies for patients with acute coronary syndromes: a systematic review and network meta-analysis. Circ Cardiovasc Interv. 2023;16:e013242.
