title: Balancing the risks of bleeding and stent thrombosis: a decision analytic model to compare durations of dual antiplatelet therapy after drug-eluting stents.
abstract: BACKGROUND
  After coronary stent placement, whether dual antiplatelet therapy (DAPT) duration should be extended to prevent late stent thrombosis (ST) or adverse cardiovascular events is uncertain.
  
  
  METHODS
  To define the reduction in ischemic events required to outweigh increased bleeding with longer-duration DAPT, we developed a decision-analytic Markov model comparing DAPT durations of 6, 12, and 30 months after DES. Separate models were developed for patients presenting with and without an acute coronary syndrome (ACS). We used sensitivity analyses to identify the incremental benefit of longer-duration DAPT on either ST or the composite of cardiac death, myocardial infarction, and ischemic stroke (major adverse cardiovascular and cerebrovascular events [MACCEs]) required to outweigh the increased risk of bleeding associated with longer DAPT. The outcome from each strategy was quantified in terms of quality-adjusted life years.
  
  
  RESULTS
  In the non-ACS population, in order for 30 months of DAPT to be preferred over 12 months of therapy, DAPT would have to result in a 78% reduction in the risk of ST (relative risk [RR] 0.22, 3.1 fewer events per 1000) and only a 5% reduction in MACCE (RR 0.95, 2.2 fewer events per 1000) as compared with aspirin alone. For the ACS population, DAPT would have to result in a 44% reduction in the risk of ST (RR 0.56, 3.4 fewer events per 1000) but only a 2% reduction in MACCE (RR 0.98, 2.3 fewer events per 1000) as compared with aspirin alone, for 30 months of DAPT to be preferred for 12 months.
  
  
  CONCLUSIONS
  Small absolute differences in the risk of ischemic events with longer DAPT would be sufficient to outweigh the known bleeding risks.
authors: Division of Cardiology, London Health Sciences Center, London, Ontario, Canada.
authors: Pallav
authors: P
authors: Garg
authors: Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors: Benjamin Z
authors: BZ
authors: Galper
authors: Division of Cardiology, Saint Luke's Mid-America Heart Institute, University of Missouri-Kansas City, Kansas City, MO.
authors: David J
authors: DJ
authors: Cohen
authors: Division of Cardiology, Massachusetts General Medical Hospital, Harvard Medical School, Boston, MA; Division of Cardiology, Harvard Clinical Research Institute, Boston, MA.
authors: Robert W
authors: RW
authors: Yeh
authors: Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Cardiology, Harvard Clinical Research Institute, Boston, MA. Electronic address: lmauri1@partners.org.
authors: Laura
authors: L
authors: Mauri
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects; D000077144:Clopidogrel; D003661:Decision Support Techniques; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D011183:Postoperative Complications / Q000517:prevention & control*; D020379:Risk Adjustment; D018570:Risk Assessment / Q000379:methods; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013995:Time; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
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