Short DAPT Followed by P2Y₁₂ Inhibitors vs DAPT Alone Following Complex PCI

A systematic review and meta-analysis published in the European Heart Journal Cardiovascular Pharmacotherapy found that bleeding outcomes are reduced when complex percutaneous coronary intervention (C-PCI) is followed with a short course of dual antiplatelet therapy (DAPT), then by P2Y₁₂ inhibitors, compared with standard DAPT alone.

Investigators from the Icahn School of Medicine at Mount Sinai in the United States searched publication databases for studies of bleeding and ischemic outcomes after PCI. A total of 5 randomized clinical trials (RCTs) published between 2018 and 2020 were included in the analysis.

The experimental arm of the included studies were 3 months of DAPT followed by P2Y₁₂ inhibitors (n=3) or 1 month of DAPT followed by P2Y₁₂ inhibitors (n=2). Three of the 4 trials used ticagrelor as the P2Y₁₂ inhibitor. The definition of C-PCI differed slightly across the trials, but in general comprised 3 or more vessels treated, 3 or more lesions treated, 2 or more stents implanted, and total stent length of 60 mm or longer.

The RCTs included a total of 34,615 patients, among whom 25.5% received C-PCI. The C-PCI cohort received short DAPT followed by P2Y₁₂ inhibitors (50.2%) or standard DAPT. Four of the trials recruited patients with chronic coronary syndrome and 1 recruited patients with acute coronary syndrome.

Primary bleeding events were reported by more C-PCI recipients (2.9%) than non-C-PCI recipients (2.2%; P <.001). Among the C-PCI cohort, risk for bleeding outcomes was lower among the P2Y₁₂ inhibitor recipients compared with standard DAPT recipients (hazard ratio [HR], 0.66; 95% CI, 0.44-0.98; I², 40.0%). This pattern was stronger among the subset of patients who received 3 months of DAPT before switching to P2Y₁₂ inhibitors.

Similarly, ischemic events occurred among more C-PCI recipients (3.1%) than non-C-PCI recipients (2.5%; P =.003). Risk for major adverse cardiovascular events tended to be reduced among the P2Y₁₂ inhibitor recipients compared with standard DAPT recipients (HR, 0.69; 95% CI, 0.48-1.00; I², 42.7%). The interaction between ischemic events and PCI complexity was significant (P =.028), in which the non-C-PCI cohort did not have different risk for ischemic events on the basis of DAPT regimen.

A similar trend was observed for the outcome of all-cause mortality, favoring the P2Y₁₂ inhibitors cohort (HR, 0.52; 95% CI, 0.32-0.87; I², 20.4%).

The findings of this analysis may have been limited by the heterogeneity observed and by the fact that some data were sourced from post-hoc analyses.

 “…our large collaborative meta-analysis of randomized trials demonstrates that a 1 to 3-month DAPT strategy followed by P2Y₁₂ inhibitor monotherapy, particularly with ticagrelor, is both safe and efficacious as compared with a standard DAPT regimen after C-PCI and non-C-PCI,” the study authors wrote.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.