Short Dual Antiplatelet Therapy Duration After Percutaneous Coronary Intervention in High Bleeding Risk Patients: Systematic Review and Meta-analysis
Kevin R. Bainey, Guillaume Marquis-Gravel, Blair J. MacDonald, David Bewick, Andrew Yan, Ricky D. Turgeon
Dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) reduces major adverse cardiovascular events (MACE) and stent thrombosis. However, DAPT duration is a concern in high bleeding risk (HBR) patients. We evaluated the effect of short DAPT (1–3 months) compared to standard DAPT (6–12 months) on bleeding and ischemic events in HBR PCI.
Dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) reduces the risk of stent thrombosis and protects from non-culprit atherothrombotic events long-term. The 2018 Canadian Cardiovascular Society (CCS)/Canadian Association of Interventional Cardiology (CAIC) Focused Update for the Use of Antiplatelet Therapy recommend DAPT with low-dose aspirin and a P2Y12 receptor inhibitor for 1 year (and up to 3 years in low bleeding / high ischemic risk patients) in acute coronary syndromes (ACS) and a minimum of 6 months (and up to 1 year) in non-ACS patients following PCI . Subsequent studies in the era of use of newer-generation drug-eluting stents (DES), which have reduced risk of stent thrombosis, have suggested that DAPT may be safely be reduced to 6 months without increasing thrombotic risk [2–4].
Materials and method
We performed a systematic review and meta-analysis according to the methodology outlined in the Cochrane Handbook for Systematic Reviews and Interventions using a prospectively-designed (but not registered) protocol, and reported following the 2020 PRISMA statement .
From 503 articles, we included five RCTs reported across 9 articles (Fig 1) involving 7,242 patients. The included studies (and subgroup analyses) were: MASTER DAPT (the only RCT exclusively enrolling patients with HBR) [19–22], and the HBR subgroup of TWILIGHT , TICO , and STOPDAPT-2 Total Cohort (which consisted of two trials: STOPDAPT-2 and STOPDAPT-2 ACS) [25–27]. S1 Table outlines the HBR definition used in each trial and proportion of patients fitting each criterion when reported.
This comprehensive systematic review and meta-analysis of HBR PCI patients demonstrated a reduction in bleeding events with shortening to SAPT following 1 to 3 months of DAPT compared to a DAPT duration of 6–12 months, without compromising MACE or all-cause mortality (Fig 4). Furthermore, the risk of stent thrombosis was ≤0.5% regardless of DAPT duration. Finally, these results were consistent regardless of clinical presentation, concomitant indication for OAC, or choice of SAPT following DAPT, though most patients received P2Y12 inhibitor monotherapy.
This comprehensive systematic review with meta-analysis demonstrated reduced risk of bleeding events with short DAPT compared with standard DAPT duration in HBR patients undergoing PCI, with no significant increase in MACE, death, or stent thrombosis. This evidence should inform clinical decision-making about DAPT duration in this vulnerable population.
Citation: Bainey KR, Marquis-Gravel G, MacDonald BJ, Bewick D, Yan A, Turgeon RD (2023) Short dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk patients: Systematic review and meta-analysis. PLoS ONE 18(9): e0291061.
Editor: R. Jay Widmer, Baylor Scott and White, Texas A&M College of Medicine, UNITED STATES
Received: March 6, 2023; Accepted: August 21, 2023; Published: September 1, 2023
Copyright: © 2023 Bainey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was conducted to support the Canadian Cardiovascular Society Antiplatelet Guidelines with funding provided to Ricky Turgeon by the Canadian Cardiovascular Society (https://ccs.ca/). The funder did not play any role in the study design, data collection or analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.