Short-term DAPT followed by P2Y12 monotherapy versus standard-term DAPT after PCI for ACS: an updated systematic review and meta-analysis of randomised controlled trials
S Sreenivasan, M Monaghan, C Gyan, Brandon Rodriguez-Tapia, J M Moreno-Miron, D E Sanchez, L Jacomino, V Kumar, R Bale, A Bezerra, G Machado, A Rehman, D Mamani-Sucari, A Oliveira, P gagliardAbstract
Background
In acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), early aspirin withdrawal with P2Y12 inhibitor monotherapy after abbreviated dual antiplatelet therapy (DAPT) may reduce bleeding, but concerns persist regarding ischaemic safety. We synthesised randomised evidence using frequentist and Bayesian methods to quantify probabilities of benefit and harm.
Methods
Cochrane Library, Embase, PubMed, and Scopus were searched for randomised trials comparing short-term DAPT (1–3 months) followed by P2Y12 inhibitor monotherapy versus standard-duration DAPT after PCI for ACS. Frequentist and Bayesian random-effects meta-analyses were performed; Bayesian models were fitted using Markov chain Monte Carlo sampling. Co-primary outcomes were all-cause mortality and clinically relevant bleeding (trial-defined). Results are reported as odds ratios (OR) with 95% confidence intervals (CI) or credible intervals (CrI) and Bayesian probabilities of benefit.
Results
Ten trials (30,873 participants) were included. Short-term DAPT halved clinically relevant bleeding (OR 0.48, 95% CI 0.41 - 0.56; I2 = 0%; Bayesian probability of benefit 100%) and major bleeding (OR 0.48, 95% CI 0.34 - 0.68; I2 = 38.7%). All-cause mortality numerically favoured short-term DAPT but did not reach significance (OR 0.89; 95% CI 0.67 to 1.19; Bayesian probability of benefit 79.5%). No increase was observed in myocardial infarction (OR 1.08; 95% CI 0.85 to 1.39), stent thrombosis (OR 1.09; 95% CI 0.72 to 1.66), or stroke (OR 0.94; 95% CI 0.68 to 1.30). Net adverse clinical events favoured short-term DAPT (OR 0.73; 95% CI 0.58 to 0.93; Bayesian probability of benefit 99.7%).
Conclusions
Short-term DAPT followed by P2Y12 inhibitor monotherapy halves bleeding without significant increase in ischaemic events in ACS patients undergoing PCI. These findings support short-term DAPT as a bleeding avoidance strategy in appropriately selected patients.Outcome1Mortality