Efficacy and Safety of Dual Antiplatelet Therapy in Patients Undergoing Coronary Stent Implantation: A Systematic Review and Network Meta-Analysis

Abstract

Introduction: This network meta-analysis aimed to evaluate the efficacy and safety of different dual antiplatelet therapies (DAPTs) after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs).

Methods: Randomized controlled trials (RCTs) comparing longer-term (>12 months) DAPT (L-DAPT), 12-month DAPT (DAPT 12Mo), 6-month DAPT (DAPT 6Mo), 3-month DAPT followed by aspirin monotherapy (DAPT 3Mo + ASA), 3-month DAPT followed by a P2Y12 receptor inhibitor monotherapy (DAPT 3Mo + P2Y12), or 1-month DAPT with a P2Y12 receptor inhibitor monotherapy (DAPT 1Mo + P2Y12) were searched. Primary endpoints were all-cause mortality, cardiac death, myocardial infarction (MI), major bleeding, any bleeding, definite or probable stent thrombosis (ST), and net adverse clinical events (NACE). This Bayesian network meta-analysis was performed with the random-effects model.

Results: Twenty-four RCTs (n = 81339) were included. In comparison with L-DAPT, DAPT 6Mo (OR: 0.50, 95% CI: 0.29-0.83), DAPT 3Mo + P2Y12 (OR: 0.38, 95% CI: 0.18-0.82), DAPT 3Mo + ASA (OR: 0.44, 95% CI: 0.17-0.98), and DAPT 1Mo + P2Y12 (OR: 0.45, 95% CI: 0.14-0.93) were associated with a lower risk of major bleeding. DAPT 3Mo + P2Y12 (OR: 0.58, 95% CI: 0.38-0.88) reduced the risk of any bleeding when compared with DAPT 12Mo. L-DAPT decreased the risk of MI and definite or probable stent ST when compared with DAPT 6Mo. DAPT 3Mo + P2Y12 decreased the risk of NACE in comparison with DAPT 6Mo and DAPT 12Mo. No significant difference in all-cause mortality and cardiac death was observed. In patients with acute coronary syndrome, DAPT 6Mo was comparable to DAPT 12Mo.

Conclusion: Short-term (1-3 months) DAPT is noninferior to DAPT 6Mo after DESs implantation, while L-DAPT reduces MI and definite or probable ST rates. DAPT 3Mo + P2Y12 might be a reasonable trade-off in patients with high risk of bleeding accompanied by ischemia.

Figure 1

PRISMA flow diagram detailing study selection.

Figure 2

Network plot of treatment comparisons. Network diagram nodes represent individual interventions and nodes connected by lines indicate that these two interventions have been directly compared in a randomized trial. The nodes are weighted by the number of randomized trials evaluating this treatment and lines are weighted by the number of randomized trials evaluating this treatment comparison. (a) Cardiac death. (b) Net adverse clinical events. (c) All-cause mortality, myocardial infarction, major bleeding, any bleeding and definite or probable stent thrombosis.

Figure 3

Forest plots. L-DAPT refers to longer-term (>12 months) DAPT, DAPT 12Mo refers to 12-month DAPT, DAPT 6Mo refers to 6-month DAPT, DAPT 3Mo + ASA refers to 3-month DAPT followed by aspirin monotherapy, DAPT 3Mo + P2Y12 refers to 3-month DAPT followed by P2Y12 receptor inhibitor monotherapy, and DAPT 1Mo + P2Y12 refers to 1-month DAPT followed by P2Y12 receptor inhibitor monotherapy. DAPT indicates dual antiplatelet therapy.

Figure 4

Rankograms for each endpoint. Rank 1 is the worst and rank 6 is best. L-DAPT refers to longer-term (>12 months) DAPT, DAPT 12Mo refers to 12-month DAPT, DAPT 6Mo refers to 6-month DAPT, DAPT 3Mo + ASA refers to 3-month DAPT followed by aspirin monotherapy, DAPT 3Mo + P2Y12 refers to 3-month DAPT followed by P2Y12 receptor inhibitor monotherapy, and DAPT 1Mo + P2Y12 refers to 1-month DAPT followed by P2Y12 receptor inhibitor monotherapy. DAPT indicates dual antiplatelet therapy. (a) All-cause mortality. (b) Cardiac death. (c) Myocardial infarction. (d) Definite or probable stent thrombosis. (e) Major bleeding. (f) Any bleeding. (g) Net adverse clinical events.