Abbreviated DAPT Duration for PCI Associated With Decrease in Major Bleeding

Abbreviated dual antiplatelet therapy (DAPT) reduces major or clinically relevant nonmajor bleeding and major bleeding without increasing major adverse cardiovascular events (MACE) in patients receiving percutaneous coronary intervention (PCI) or with acute coronary syndrome (ACS) and a concomitant oral anticoagulation (OAC) indication, according to a study in the European Heart Journal—Cardiovascular Pharmacotherapy.

Researchers conducted a systematic review and meta-analysis to assess the impact of DAPT duration after PCI regardless of OAC type in patients with an indication for this treatment.

An electronic database search was performed from January 1, 2000, to September 1, 2021, for randomized controlled trials (RCTs) of adult patients who received an abbreviated (<3 months) or prolonged (≥3 months) DAPT duration with concomitant indication for OAC therapy.

The 2 coprimary endpoints were major bleeding and major or clinically relevant nonmajor bleeding. The key safety endpoint was the composite of MACE at the longest follow-up.

A total of 5 RCTs with 7665 patients (3843 in the abbreviated DAPT group and 3822 in the prolonged DAPT group) were included. The overall mean age was 72 years, and the prolonged DAPT arm had a mean DAPT duration of 6 months. DOACs were used in 46.7% of cases, with apixaban accounting for 81.5% of DOAC use. Clopidogrel (79.2%) was the most frequently used single antiplatelet agent after DAPT discontinuation in the abbreviated DAPT arm.

The abbreviated regimen was associated with a significantly decreased risk for the coprimary endpoints of major or clinically relevant nonmajor bleeding (10.2% vs 16.3%; risk ratio [RR], 0.69; 95% CI, 0.52-0.91; P =.01; I²=76%; number needed to treat [NNT], 16.4) and major bleeding (3.4% vs 5.1%; RR, 0.70; 95% CI, 0.52-0.95; P =.01; I²=33%; NNT, 58.8), compared with a prolonged DAPT regimen. A sensitivity analysis including only patients who had received PCI demonstrated consistent results (RR for major or clinically relevant nonmajor bleeding, 0.67; 95% CI, 0.46-0.96; P =.03).

The meta-regression analysis for major or clinically relevant nonmajor bleeding and major bleeding showed a significantly increased protective effect with a P2Y₁₂ inhibitor as the drug to continue after DAPT discontinuation in the abbreviated DAPT cohort (RR, 0.59; 95% CI, 0.34-0.98; P =.05 for major or clinically relevant nonmajor bleeding and RR, 0.44; 95% CI, 0.22-0.87; P =.01 for major bleeding).

The abbreviated and prolonged DAPT regimens did not have a significant difference in the key safety endpoint of MACE (7.1% vs 7.0%; RR, 0.96; 95% CI, 0.70-1.33; P =.6; I²=60%). The finding was consistent when an alternative MACE endpoint that included only cardiovascular mortality was used (RR, 0.95; 95% CI, 0.75-1.2; P =.7; I²=60%).

The network meta-analysis also assessed bleeding and ischemic endpoints in periprocedural vs short (4-6 weeks) or prolonged DAPT (≥3 months). Periprocedural DAPT was the most beneficial treatment for reducing bleeding events (surface under cumulative ranking curve analysis for major or clinically relevant nonmajor bleeding and major bleeding: 97.1% and 92.0%, respectively).

Study limitations include use of an aggregate-data meta-analysis, and formal statistical significance is not maintained in the random-effects sensitivity analysis excluding 2 trials. In addition, heterogeneity is observed in the clinical endpoint definitions among the included studies, and mild heterogeneity occurred in the follow-up durations.

“Periprocedural DAPT and continuation with a P2Y₁₂ inhibitor rather than aspirin after DAPT discontinuation appear to augment the benefit of an abbreviated DAPT course but this is based on limited evidence at present,” the investigators wrote.

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.