Short Duration of DAPT Versus De-Escalation After Percutaneous Coronary Intervention for Acute Coronary Syndromes

• Published in: JACC. Cardiovascular interventions 2022-02, Vol.15 (3), p.268-277
• Main Authors: Laudani, Claudio, Greco, Antonio, Occhipinti, Giovanni, Ingala, Salvatore, Calderone, Dario, Scalia, Lorenzo, Agnello, Federica, Legnazzi, Marco, Mauro, Maria Sara, Rochira, Carla, Buccheri, Sergio, Mehran, Roxana, James, Stefan, Angiolillo, Dominick J., Capodanno, Davide
• Format: Article
• Language: English
• Subjects: Acute Coronary Syndrome - therapy; acute coronary syndrome(s); Bayes Theorem; Dual Anti-Platelet Therapy - adverse effects; Dual Anti-Platelet Therapy - methods; dual antiplatelet therapy; Humans; network meta-analysis; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors - administration & dosage; Platelet Aggregation Inhibitors - adverse effects; Treatment Outcome
• ISSN: 1936-8798; 1876-7605; 1876-7605
• DOI: 10.1016/j.jcin.2021.11.028

The aim of this study was to compare short dual antiplatelet therapy (DAPT) and de-escalation in a network meta-analysis using standard DAPT as common comparator. In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), shortening DAPT and de-escalating to a lower potency regimen mitigate bleeding risk. These strategies have never been randomly compared. Randomized trials of DAPT modulation strategies in patients with ACS undergoing PCI were identified. All-cause death was the primary outcome. Secondary outcomes included net adverse cardiovascular events (NACE), major adverse cardiovascular events, and their components. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on the basis of posterior probability. Sensitivity analyses were performed to explore sources of heterogeneity. Twenty-nine studies encompassing 50,602 patients were included. The transitivity assumption was fulfilled. In the frequentist indirect comparison, the risk ratio (RR) for all-cause death was 0.98 (95% CI: 0.68-1.43). De-escalation reduced the risk for NACE (RR: 0.87; 95% CI: 0.70-0.94) and increased major bleeding (RR: 1.54; 95% CI: 1.07-2.21). These results were consistent in the Bayesian meta-analysis. De-escalation displayed a >95% probability to rank first for NACE, myocardial infarction, stroke, stent thrombosis, and minor bleeding, while short DAPT ranked first for major bleeding. These findings were consistent in node-split and multiple sensitivity analyses. In patients with ACS undergoing PCI, there was no difference in all-cause death between short DAPT and de-escalation. De-escalation reduced the risk for NACE, while short DAPT decreased major bleeding. These data characterize 2 contemporary strategies to personalize DAPT on the basis of treatment objectives and risk profile. [Display omitted]