title: Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients.
abstract: We sought to determine whether the optimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation.
  
  
  
  We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary study outcome was the 1-year composite risk of myocardial infarction (MI) or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MI or ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P = 0.71; Pinteraction = 0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MI or ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS.
  
  
  
  Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify the optimal duration of DAPT after DES in individual patients based on their relative ischaemic and bleeding risks.
authors.affiliation: Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy.
authors.forename: Tullio
authors.initials: T
authors.lastname: Palmerini
authors.affiliation: Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Della Riva
authors.affiliation: Bristol Heart Institute, University of Bristol School of Clinical Sciences, Bristol, Bristol, UK.
authors.forename: Umberto
authors.initials: U
authors.lastname: Benedetto
authors.affiliation: Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy.
authors.forename: Letizia
authors.initials: L
authors.lastname: Bacchi Reggiani
authors.affiliation: Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
authors.forename: Fausto
authors.initials: F
authors.lastname: Feres
authors.affiliation: Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Abizaid
authors.affiliation: Department of Cardiology, Brest University, Brest, France.
authors.forename: Martine
authors.initials: M
authors.lastname: Gilard
authors.affiliation: Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Morice
authors.affiliation: Swiss Cardiovascular Center, Bern, Switzerland.
authors.forename: Marco
authors.initials: M
authors.lastname: Valgimigli
authors.affiliation: Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Myeong-Ki
authors.initials: MK
authors.lastname: Hong
authors.affiliation: Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Byeong-Keuk
authors.initials: BK
authors.lastname: Kim
authors.affiliation: Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Yangsoo
authors.initials: Y
authors.lastname: Jang
authors.affiliation: Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
authors.forename: Hyo-Soo
authors.initials: HS
authors.lastname: Kim
authors.affiliation: Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
authors.forename: Kyung Woo
authors.initials: KW
authors.lastname: Park
authors.affiliation: San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.affiliation: San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Alaide
authors.initials: A
authors.lastname: Chieffo
authors.affiliation: Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy.
authors.forename: Diego
authors.initials: D
authors.lastname: Sangiorgi
authors.affiliation: Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, and Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Biondi-Zoccai
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY.
authors.forename: Philippe
authors.initials: P
authors.lastname: Généreux
authors.affiliation: Bristol Heart Institute, University of Bristol School of Clinical Sciences, Bristol, Bristol, UK.
authors.forename: Gianni D
authors.initials: GD
authors.lastname: Angelini
authors.affiliation: Bristol Heart Institute, University of Bristol School of Clinical Sciences, Bristol, Bristol, UK.
authors.forename: Maria
authors.initials: M
authors.lastname: Pufulete
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY.
authors.forename: Jonathon
authors.initials: J
authors.lastname: White
authors.affiliation: Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY.
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy*; D000704:Analysis of Variance; D001241:Aspirin / Q000008:administration & dosage; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000401:mortality; D000077144:Clopidogrel; D003324:Coronary Artery Disease / Q000401:mortality / Q000628:therapy*; D016757:Death, Sudden, Cardiac / Q000453:epidemiology; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality; D009204:Myocardial Revascularization / Q000379:methods / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D020521:Stroke / Q000401:mortality; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
keywords: Drug-eluting stent; Dual antiplatelet therapy; Stent thrombosis