The optimal discontinuation of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention with drug-eluting stents: A meta-analysis of randomized trials

Abstract

BackgroundCurrent guidelines recommend prolonged dual antiplatelet therapy (DAPT) for patients with drug-eluting stents (DES) implantation. Nevertheless, optimal discontinuation of DAPT remains a controversy. We performed a meta-analysis of all randomized controlled trials (RCTs) that evaluate optimal discontinuation of DAPT in patients undergoing percutaneous coronary intervention (PCI) with DES. MethodsWe searched electronic databases including PubMed, Cochrane Library, EMBASE and ClinicalTrials.gov from database RCTs that reported different modes of discontinuation of DAPT in patients with DES. The primary endpoints were all-cause death, cardiovascular death, myocardial infarction (MI) and probably or definite stent thrombosis (ST). Secondary endpoints were repeat revascularization, stroke, major bleeding and net adverse clinical events (NACE). ResultsWe included 13 RCTs meeting the criteria with a total of 36,749 patients. No significant difference was observed in all-cause death (RR [95% CI]=0.87 [0.75, 1.01], P=0.07, I2=0%), cardiovascular death (RR [95% CI]=0.97 [0.79, 1.19], P=0.76, I2=0%), repeat revascularization (RR [95% CI]=1.07 [0.92, 1.25], P=0.36, I2=0%), and stroke (RR [95% CI]=1.01 [0.80, 1.28], P=0.94, I2=0%). Compared with shorter DAPT, longer DAPT was associated with a significant reduction in MI (RR [95% CI]=1.46 [1.26, 1.69], P<0.00001, I2=28%) and ST (RR [95% CI]=1.93 [1.45, 2.58], P<0.00001, I2=32%), and a significant increase in major bleeding (RR [95% CI]=0.60 [0.49, 0.74], P<0.00001, I2=0%). However, there was no difference in NACE (RR [95% CI]=1.03 [0.91, 1.17], P=0.63, I2=0%). In subgroup analyses based on stent type, we demonstrated that longer DAPT was associated with a significant reduction in thrombotic events (MI and ST) after first-generation DES implantation (RR [95% CI]=2.58 [1.85, 3.58], I2=0%) and everolimus-eluting stents (EES, RR [95% CI]=1.54 [1.12, 2.11], I2=0%). Conversely, there was no difference in thrombotic events in patients with zotarolimus-eluting stents (ZES, RR [95% CI]=1.17 [0.83, 1.63], I2=75%) and biodegradable polymer DES (BP-DES, RR [95% CI]=1.15 [0.74, 1.79]). Conclusions1) Compared with shorter DAPT, longer DAPT was associated with a significant reduction in thrombotic events (MI and ST) and a higher rate of major bleeding. 2) By the assessment of the trade-off between thrombotic and hemorrhagic events, shorter DAPT was non-inferior to longer DAPT. 3) The benefit of longer DAPT was significant in patients with first-generation DES and EES and weakened with other second-generation DES (ZES and BP-DES).