Abbreviated Dual Antiplatelet Therapy Followed by P2Y12 Inhibitor Monotherapy versus 12 Months’ Dual Antiplatelet Therapy Post Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract

An increased incidence of stent thrombosis after implantation of first-generation drug-eluting stents led to a recommendation of dual antiplatelet therapy (DAPT) for 12months after the procedure. However, given the use of second-generation and newer drug-eluting stents, this recommendation needs to be revisited. Several randomized controlled trials (RCTs) have studied an abbreviated DAPT regimen of ≤ 3months followed by P2Y12 inhibitor monotherapy, and results have been conflicting. We performed a systematic review with meta-analysis of RCTs of abbreviated DAPT for ≤ 3months followed by P2Y12 monotherapy compared with 12months of DAPT. We performed a systematic search of the MEDLINE/PubMed, Cochrane, and DARE (Database of Abstracts of Reviews of Effects) databases for eligible RCTs. Quantitative analysis was performed based on the intention-to-treat principle. We used the Mantel-Haenszel method with a random-effects model to calculate relative risks (RRs) with 95% confidence intervals (CIs). The final analysis included four RCTs. We found no difference in the risk of all-cause mortality (RR 0.90; 95% CI 0.77-1.05; p = 0.18; I2 = 0%; χ2p = 0.58), myocardial infarction (RR 0.99; 95% CI 0.86-1.15; p = 0.85; I2 = 0%; χ2p = 0.70), stroke (RR 1.14; 95% CI 0.65-1.98; p = 0.65; I2 = 59%; χ2p = 0.06), or stent thrombosis (RR 0.98; 95% CI 0.73-1.33; p = 0.90; I2 = 0%; χ2p = 0.48). Additionally, there was no difference in the risk for major bleeding, defined as BARC (Bleeding Academic Research Consortium) type 3 or 5, between the two groups (RR 0.62; 95% CI 0.37-1.05; p = 0.07; I2 = 79%; χ2p < 0.05). Abbreviated DAPT followed by P2Y12 monotherapy resulted in a similar risk of re-ischemic clinical outcomes post percutaneous coronary intervention as compared with the standard 12-month DAPT regimen. The risk of major bleeding (BARC type 3 or 5) also remained similar between the two groups. However, as trials have reported benefits with abbreviated DAPT followed by P2Y12 monotherapy in terms of combined endpoints and all bleeding (BARC type 2-5), additional research is needed.