title: Optimal Duration of Dual Antiplatelet Therapy after Drug-Eluting Stents: Meta-Analysis of Randomized Trials.
abstract: BACKGROUND
  The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation (DES) is not certain. The AHA/ACC guidelines recommend 12 months of DAPT based on observational trials. Recently, several large randomized controlled trials (RCT) suggested a noninferiority of shorter duration of DAPT and other trials showed a benefit from extended duration of DAPT after 12 months of DES implantation.
  
  
  METHODS
  PubMed databases were searched for RCTs comparing the continued use of DAPT to shorter duration of DAPT (aspirin alone) for variable durations beyond 3 months of DES implantation. Our analysis was limited to trials with clinical outcomes. Odds ratio (OR) and 95% confidence intervals (CI) were calculated using fixed and random-effects models. Subgroup analyses were performed for second generation DES and for trials comparing 12 months of DAPT vs. earlier interruption or longer duration of DAPT.
  
  
  RESULTS
  We identified 10 RCTs including 32,136 subjects randomized to continued use of DAPT vs. aspirin alone for variable durations after 3 months of DES implantation. There was no significant heterogeneity among studies (Q test P > 0.1). Compared to shorter DAPT, longer DAPT resulted in a significant reduction in stent thrombosis (0.3% vs. 0.7%, P < 0.01) and myocardial infarction (1.3% vs. 2%, P < 0.01), and a significant increase in major bleeding (0.8% vs. 0.4%, P < 0.01). There was no difference in cardiac deaths or stroke. All-cause deaths were slightly lower with shorter DAPT compared to longer DAPT (OR 0.8, 95% CI 0.7 to 0.99, P = 0.04). A small number of subjects were included between 3 and 6 months after DES implantation.
  
  
  CONCLUSIONS
  DAPT continued beyond 6 months after second generation DES implantation decreases stent thrombosis and myocardial infarction, but increases major bleeding and all-causes mortality compared to shorter DAPT (aspirin alone). There was no difference in cardiac mortality or stroke.
authors.affiliation: Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Elsayed
authors.initials: E
authors.lastname: Abo-Salem
authors.affiliation: Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Said
authors.initials: S
authors.lastname: Alsidawi
authors.affiliation: Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Hina
authors.initials: H
authors.lastname: Jamali
authors.affiliation: Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Effat
authors.affiliation: Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: Tarek
authors.initials: T
authors.lastname: Helmy
mesh_terms: D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects; D016001:Confidence Intervals; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D009203:Myocardial Infarction / Q000517:prevention & control; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D016032:Randomized Controlled Trials as Topic; D013927:Thrombosis / Q000517:prevention & control; D013997:Time Factors
chemical_list: D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
keywords: Drug-eluting stents; Dual antiplatelet therapy; Stent thrombosis