Abstract 12107: Short-Term and De-Escalation Dual Antiplatelet Therapy for Patients With Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis

Abstract

Background: Short-term (<6 month) or de-escalation (e.g. switching potent P2Y 12 inhibitors to less potent/lower-dose agents a month after the event) dual antiplatelet therapy (DAPT) have become an attractive therapeutic strategy for patients with acute coronary syndrome (ACS). However, these strategies have never been randomly compared. Methods: PubMed, EMBASE, and Cochrane Central were searched in April 2022. Randomized controlled trials (RCTs) or their subgroup analyses that included ACS patients, with standard (12 months), extended (≥18 months), short-term and unguided de-escalation DAPT strategy, along with the guided DAPT strategy with genotype or platelet function tests were identified. The efficacy outcome (major adverse cardiovascular events: MACE) was defined as a composite of cardiovascular death, myocardial infarction, or stroke. The safety outcomes were mainly defined as major or minor bleeding, and major bleeding. Results: This network meta-analysis included 32 RCTs with 103,497 patients. While there was no significant difference in efficacy among the short DAPT, unguided de-escalation and guided-selection strategy, the unguided de-escalation strategy alone was associated with reduced risks of MACE compared with standard DAPT (e.g. versus DAPT with clopidogrel; HR [95% CI]: 0.66 [0.48-0.91]). Both the short DAPT and de-escalation strategies were associated with reduced risks of major or minor bleeding compared with other strategies including the guided-selection (HR [95% CI]: 0.66 [0.47-0.93], 0.48 [0.33-0.71], respectively); the short DAPT strategy alone was associated with a reduced risk of major bleeding compared with standard, extended and guided-selection DAPT (HR [95%CI]: 0.55 [0.33-0.92]). Conclusions: In ACS patients, the unguided de-escalation strategy was associated with reduced risks of MACE, while the short DAPT strategy was associated with decreased rates of major bleeding compared with standard DAPT, suggesting both strategies can be used in select patients by balancing patients’ ischemic and bleeding risks.