Longer- Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement: A Systematic Review and Meta-analysis

Ann Intern Med. 2015 Jul 21;163(2):118-26. doi: 10.7326/M15-0083.


Background: The appropriate duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) placement remains controversial.

Purpose: To summarize data on clinical outcomes with longer- versus shorter-duration DAPT after DES placement in adults with coronary artery disease.

Data sources: Ovid MEDLINE and EMBASE, 1996 to 27 March 2015, and manual screening of references.

Study selection: Randomized, controlled trials comparing longer- versus shorter-duration DAPT after DES placement.

Data extraction: Two reviewers screened potentially eligible articles; extracted data on populations, interventions, and outcomes; assessed risk of bias; and used the Grading of Recommendations Assessment, Development and Evaluation guidelines to rate overall confidence in effect estimates.

Data synthesis: Among 1010 articles identified, 9 trials including 29,531 patients were eligible; data were complete for 28,808 patients. Moderate-quality evidence showed that longer-duration DAPT decreased risk for myocardial infarction (risk ratio [RR], 0.73 [95% CI, 0.58 to 0.92]) and increased mortality (RR, 1.19 [CI, 1.04 to 1.36]). High-quality evidence showed that DAPT increased risk for major bleeding (RR, 1.63 [CI, 1.34 to 1.99]).

Limitation: Confidence in estimates were decreased owing to imprecision for most outcomes (particularly myocardial infarction), risk of bias from limited blinding in 7 of 9 studies, indirectness due to variability in use of first- and second-generation stents, and off-protocol use of DAPT in some studies.

Conclusion: Extended DAPT is associated with approximately 8 fewer myocardial infarctions per 1000 treated patients per year but 6 more major bleeding events than shorter-duration DAPT. Because absolute effects are very small and closely balanced, decisions regarding the duration of DAPT therapy must take into account patients' values and preference.

Primary funding source: None.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Cause of Death
  • Coronary Artery Disease / mortality
  • Coronary Artery Disease / surgery
  • Drug Administration Schedule
  • Drug Therapy, Combination
  • Drug-Eluting Stents*
  • Hemorrhage / chemically induced
  • Humans
  • Myocardial Infarction / prevention & control
  • Percutaneous Coronary Intervention / instrumentation*
  • Platelet Aggregation Inhibitors / administration & dosage*
  • Platelet Aggregation Inhibitors / adverse effects
  • Reoperation
  • Risk Assessment


  • Platelet Aggregation Inhibitors