medwireNews: One month of dual antiplatelet therapy (DAPT) followed by monotherapy with a P2Y12 inhibitor can significantly reduce the risk for major bleeding in patients with acute coronary syndromes (ACS) who have undergone percutaneous coronary intervention (PCI) with drug-eluting stents (DES), compared with the standard 12 months of dual therapy, report researchers.
Furthermore, a short-term DAPT protocol does not increase the risk for major adverse cardiac and cerebrovascular events (MACCE), show results of the systematic review and meta-analysis involving 35,326 ACS patients.
“The optimal duration of DAPT and the agent of choice for subsequent [single antiplatelet therapy] after DES implantation are still under debate,” remark Renato Lopes (Duke University School of Medicine, Durham, North Carolina, USA) and colleagues in JAMA Cardiology.
They believe their findings provide “contemporary insights to inform clinical practice” for this patient population.
The team assessed the results from 15 randomized controlled trials involving ACS patients aged a mean of 63 years (76% men), of whom 32% had an ST-elevation myocardial infarction and 98% received new-generation DES. Study follow-up ranged from 12 to 24 months.
Study protocols included short-term DAPT regimens of 1, 3, or 6 months’ followed by P2Y12 inhibitor (clopidogrel/prasugrel/ticagrelor) or aspirin monotherapy, and the conventional, longer-term protocol of 12 months’ DAPT, followed by aspirin monotherapy.
In the studies with 1- and 3-month DAPT regimens, the majority of participants (89% and 86% respectively) received a potent P2Y12 inhibitor – either prasugrel or ticagrelor – whereas for other regimens clopidogrel was more commonly used.
The incidence of MACCE was reported in all 15 studies and while definitions varied, all-cause or cardiovascular mortality and myocardial infarction were always included. Almost 4% of study participants experienced MACCE, and their risk for doing so was no more significant after 1 or 3 months of DAPT followed by a P2Y12 inhibitor than with 12 months of DAPT, with respective risk ratios of 1.00 and 0.85, report Lopes et al.
The incidence of MACCE was increased, albeit not significantly, with 3 months of DAPT followed by aspirin (risk ratio=1.29) and again there was no significant difference between 6 months of DAPT followed by aspirin and the 12-month protocol.
Ten studies in the analysis reported a total of 556 (1.8%) major bleeding events, defined as either Bleeding Academic Research Consortium (BARC) types 3 or 5, or Thrombolysis in Myocardial Infarction major. Patients who underwent 1 month’s DAPT treatment followed by a P2Y12 inhibitor had a significant 53% reduced risk for experiencing major bleeding compared with their counterparts who received 12 months of DAPT.
For patients receiving 3 months of DAPT followed by a P2Y12 inhibitor or aspirin, the risk was reduced nonsignificantly compared with 12 months of DAPT by a respective 47% and 18%, and for those given DAPT for 6 months followed by aspirin the risk was increased a nonsignificant 26%.
Lopes and co-authors ranked the treatments using the surface under the cumulative ranking curve method and found that 1 month of DAPT followed by a P2Y12 inhibitor was optimal for reducing major bleeding, while 3 months of DAPT followed by a P2Y12 inhibitor reduced MACCE to the greatest degree.
“After an ACS, DAPT with aspirin and potent P2Y12 inhibitors is recommended by current guidelines for 12 months in most patients, to mitigate the risk of stent thrombosis and recurrent ischemic events,” write Lopes and colleagues.
However, they explain that “in the era of newer-generation DES,” which are “more biocompatible, thinner, and sometimes devoid of polymers for drug delivery,” the risk for inflammation, stent thrombosis, myocardial infarction, and target-vessel revascularization is lower.
Therefore “long-term DAPT, which inherently imposes an ongoing risk of bleeding, may not be required.”
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