Duration of dual antiplatelet therapy after various drug-eluting stent implantation.
OBJECTIVE
To evaluate efficacy and safety of long duration dual anti-platelet therapy i.e., >12months (L-DAPT) and short duration DAPT i.e., ≤12months (S-DAPT) after various drug-eluting stent (DES) implantation.


METHODS
We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the effect of L-DAPT versus S-DAPT after sirolimus-eluting (Cypher®); paclitaxel-eluting stents (Taxus®); zotarolimus-eluting (Endeavor®) and everolimus-eluting stents (Xience V®) implantation. Odds ratio (OR) and 95% confidence intervals (CI) were calculated using random-effects models. Subgroup analyses were performed comparing two second generation DES and for RCTs comparing S-DAPT and L-DAPT.


RESULTS
We included six RCTs that randomized 19,012 patients to S-DAPT versus L-DAPT (4638 in first generation DES; 14,374 in second generation DES; 8099 EES; 4876 in ZES). Compared with L-DAPT, S-DAPT was associated with a higher rate of myocardial infarction (MI) and stent thrombosis (ST) after first [2.65 (1.88, 3.73) and 3.85 (2.14-6.93) respectively] and a higher rate of MI after second generation DES [1.33 (1.06, 1.67)]. There were no significant differences in the rates of all cause mortality, cardiovascular (CV) mortality and stroke with L-DAPT and S-DAPT after implantation of first [0.97 (0.52, 1.81); 1.19 (0.52-2.70); and 1.12 (0.36-3.52) respectively] and second generation DES [0.93 (0.69, 1.25); 0.93 (0.63, 1.36); and 0.58 (0.19, 1.75), respectively]. On further analysis of type of second generation DES, S-DAPT continues to show a higher rate of MI and ST after EES implantation [1.54 (1.11, 2.13) and 2.68 (1.20-5.94) respectively]; however there was no significant difference in the rate of MI and ST with S-DAPT and L-DAPT after ZES implantation [1.07 (0.44, 2.61) and 1.11(0.39, 3.13), respectively].


CONCLUSIONS
1) Compared with L-DAPT, S-DAPT was associated with a higher rate of MI without any significant difference in the rate of all cause mortality, CV mortality and stroke after first and second generation DES. 2) Rate of ST was also higher with S-DAPT compared to L-DAPT after first generation DES implantation; however, it was not significantly different after second generation DES. 3) On further subgroup analysis of second-generation stent there was no significant difference in the rate of all cause mortality, CV mortality, MI, ST and stroke with S-DAPT and L-DAPT after ZES implantation. S-DAPT may be optimal for newer generation stents particularly ZES.
Division of Cardiovascular Medicine, State University of New York Downstate Medical Center, New York, NY, United States. Electronic address: abhisheksharma4mamc@gmail.com.
Abhishek
A
Sharma
Department of Cardiovascular Medicine, Heart & Vascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States.
Samin K
SK
Sharma
Division of Cardiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, OH, United States.
Ajay
A
Vallakati
Department of Medicine, James J. Peters VA Medical Center, Mount Sinai School of Medicine, New York, NY, United States.
Akash
A
Garg
Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA, United States.
Carl J
CJ
Lavie
Division of Cardiology, Texas Tech University, El Paso, TX, United States.
Debabrata
D
Mukherjee
Division of Cardiovascular Medicine, State University of New York Downstate Medical Center, New York, NY, United States.
Jonathan D
JD
Marmur
D004334:Drug Administration Schedule; D054855:Drug-Eluting Stents / Q000639:trends; D006801:Humans; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000379:methods / Q000639:trends; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors
Drug-eluting stents; Dual anti-platelet therapy