Monotherapy with P2Y12-inhibitors after dual antiplatelet therapy: Filling gaps in evidence

Abstract

Background: Whether P2Y₁₂ inhibitor monotherapy (P2Y₁₂-I) is superior to aspirin following DAPT discontinuation post-PCI remains to be established.

Methods: We updated our prior network meta-analysis where P2Y₁₂-I and aspirin had been compared with DAPT or directly with each other. The focus is specifically on the available direct evidence, now consisting of the three head-to-head comparisons of P2Y₁₂-I and aspirin in event-free PCI patients after DAPT. We include a Trial Sequential Analysis of the direct evidence based on meta-analytical literature.

Results: The main finding reveals a 39% significantly lower risk of myocardial infarction with P2Y₁₂-I (RR 0.61, 95% CI 0.47-0.78, p = 0.0001, I² = 0%) with no difference in bleeding. Trial Sequential Analysis demonstrates clinically meaningful evidence for a reduction in the incidence of myocardial infarction with P2Y₁₂-I that is also supported by statistical significance.

Conclusions: Accruing data highlight that P2Y₁₂-I following DAPT discontinuation after PCI is associated with lower risk for MI and a similar risk for bleeding as compared with ASA. In light of potential limitations to the widespread adoption of life-long P2Y₁₂-I treatment, clinicians should consider identifying selected patients who are expected to derive the highest benefit.

Keywords: Aspirin; Dual antiplatelet therapy; Percutaneous coronary intervention; Trial sequential analysis; meta-analysis.