Short Dual Antiplatelet Therapy vs De-escalation Following PCI in Patients With ACS

In patients with acute coronary syndrome (ACS) who are undergoing percutaneous coronary intervention (PCI), no difference has been reported in all-cause death between the use of short dual antiplatelet therapy (DAPT) and the use of de-escalation. The use of de-escalation was linked to a reduced risk for net adverse cardiovascular events (NACE), however, whereas the use of short DAPT was associated with a reduced risk for major bleeding. These findings were published in the journal JACC: Cardiovascular Interventions.

The study was a meta-analysis of published randomized trials of DAPT modulation strategies among patients with ACS receiving PCI. Researchers sought to compare the use of DAPT and de-escalation in a network meta-analysis that used DAPT as the common comparator, recognizing that these strategies had never been randomly compared in the past. The primary study outcome was all-cause death. Secondary study outcomes included NACE, major adverse cardiovascular events, and their components. Frequentist and Bayesian network meta-analyses were carried out.

Following a screening procedure, 29 studies that involved a total of 50,602 patients were chosen for the analysis, all of which were reviewed for quality. Of the 29 studies, 15 were performed entirely in ACS cohorts and 14 ACS subgroup analyses were derived from trials conducted in all-comer PCI cohorts. Randomization took place before or close to the time of PCI in 21 of the studies, at 1 to 6 months following PCI in 7 of the studies, and at the time of PCI or at 3 months in 1 of the studies.

In the frequentist indirect comparison, the risk ratio (RR) for all-cause mortality was 0.98 (95% CI, 0.68-1.43). The use of de-escalation reduced the risk for NACE (RR, 0.87; 95% CI, 0.70-0.94) and increased the rate of major bleeding (RR, 1.54; 95% CI, 1.07-2.21). These results were consistent in the Bayesian meta-analysis.

The use of de-escalation exhibited a greater than 95% probability to rank as the best treatment strategy for NACE, stroke, stent thrombosis, myocardial infarction, and minor bleeding, whereas the use of short DAPT exhibited a greater than 95% probability to rank as the best treatment strategy for major bleeding only. These study findings were consistent both in node-split and in multiple sensitivity analyses.

A major limitation of the current analysis is that all comparisons of short DAPT vs de-escalation relied on the use of indirect evidence, which is consistent with the study rationale. Thus, the researchers were unable to verify the consistency in treatment estimates with direct vs indirect evidence. Additionally, the annualized risk for death was similar in the 2 control arms, thus implying fulfillment of the transitivity assumption.

“In the absence of direct randomized comparisons, these data may inform clinicians on the relative merits of 2 contemporary DAPT strategies and allow personalized treatment decisions on the basis of treatment objectives and the balance between the risks for thrombosis and bleeding,” the investigators wrote.

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

Reference  

Laudani C, Greco A, Occhipinti G, et al. Short duration of DAPT versus de-escalation after percutaneous coronary intervention for acute coronary syndromes.  JACC Cardiovasc Interv. Published online February 15, 2022. doi:10.1016/j.jcin.2021.11.028