Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes. A Systematic Review and Network Meta-Analysis

Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes. A Systematic Review and Network Meta-Analysis JAMA Cardiol. Published online October 9, 2024. doi:10.1001/jamacardio.2024.3216 Abstract Importance  : The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.  Objectives:   To analyze the efficacy and safety of dual antiplatelet therapy strategies in patients with acute coronary syndromes using a bayesian network meta-analysis.  Data Sources : MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.  Study Selection :  Randomized clinical trials (RCTs) comparing dual antiplatelet therapy duration strategies in patients with acute coronary syndromes undergoing percutaneous coronary intervention were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of dual antiplatelet therapy followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of dual antiplatelet therapy followed by aspirin) were compared with conventional 12 months of dual antiplatelet therapy.  Data Extraction and Synthesis: This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).  Main Outcomes and Measures :  The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.  Results:  A total of 15 RCTs randomizing 35 ,326  patients (mean [SD] age, 63.1 [11.1] years; 26 ,954  male [76.3%]; 11 ,339  STEMI [32.1%]) with acute coronary syndromes were included. A total of 24, 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of dual antiplatelet therapy, 1 month of dual antiplatelet therapy followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in major adverse cardiac and cerebrovascular events (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in major adverse cardiac and cerebrovascular events incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of dual antiplatelet therapy followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of dual antiplatelet therapy followed by P2Y12 inhibitors as optimal for reducing major adverse cardiac and cerebrovascular events (RR, 0.85; 95% CrI, 0.56-1.21).  Conclusion and Relevance:  Results of this systematic review and network meta-analysis reveal that, in patients with acute coronary syndromes undergoing percutaneous coronary intervention with DES, 1 month of dual antiplatelet therapy followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing major adverse cardiac and cerebrovascular events when compared with 12 months of dual antiplatelet therapy. However, an increased risk of major adverse cardiac and cerebrovascular events cannot be excluded, and 3 months of dual antiplatelet therapy followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce major adverse cardiac and cerebrovascular events. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear. Disclaimer: Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the ­­­STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.