title: The optimal discontinuation of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention with drug-eluting stents: A meta-analysis of randomized trials.
abstract: BACKGROUND
  Current guidelines recommend prolonged dual antiplatelet therapy (DAPT) for patients with drug-eluting stents (DES) implantation. Nevertheless, optimal discontinuation of DAPT remains a controversy. We performed a meta-analysis of all randomized controlled trials (RCTs) that evaluate optimal discontinuation of DAPT in patients undergoing percutaneous coronary intervention (PCI) with DES.
  
  
  METHODS
  We searched electronic databases including PubMed, Cochrane Library, EMBASE and ClinicalTrials.gov from database RCTs that reported different modes of discontinuation of DAPT in patients with DES. The primary endpoints were all-cause death, cardiovascular death, myocardial infarction (MI) and probably or definite stent thrombosis (ST). Secondary endpoints were repeat revascularization, stroke, major bleeding and net adverse clinical events (NACE).
  
  
  RESULTS
  We included 13 RCTs meeting the criteria with a total of 36,749 patients. No significant difference was observed in all-cause death (RR [95% CI]=0.87 [0.75, 1.01], P=0.07, I2=0%), cardiovascular death (RR [95% CI]=0.97 [0.79, 1.19], P=0.76, I2=0%), repeat revascularization (RR [95% CI]=1.07 [0.92, 1.25], P=0.36, I2=0%), and stroke (RR [95% CI]=1.01 [0.80, 1.28], P=0.94, I2=0%). Compared with shorter DAPT, longer DAPT was associated with a significant reduction in MI (RR [95% CI]=1.46 [1.26, 1.69], P<0.00001, I2=28%) and ST (RR [95% CI]=1.93 [1.45, 2.58], P<0.00001, I2=32%), and a significant increase in major bleeding (RR [95% CI]=0.60 [0.49, 0.74], P<0.00001, I2=0%). However, there was no difference in NACE (RR [95% CI]=1.03 [0.91, 1.17], P=0.63, I2=0%). In subgroup analyses based on stent type, we demonstrated that longer DAPT was associated with a significant reduction in thrombotic events (MI and ST) after first-generation DES implantation (RR [95% CI]=2.58 [1.85, 3.58], I2=0%) and everolimus-eluting stents (EES, RR [95% CI]=1.54 [1.12, 2.11], I2=0%). Conversely, there was no difference in thrombotic events in patients with zotarolimus-eluting stents (ZES, RR [95% CI]=1.17 [0.83, 1.63], I2=75%) and biodegradable polymer DES (BP-DES, RR [95% CI]=1.15 [0.74, 1.79]).
  
  
  CONCLUSIONS
  1) Compared with shorter DAPT, longer DAPT was associated with a significant reduction in thrombotic events (MI and ST) and a higher rate of major bleeding. 2) By the assessment of the trade-off between thrombotic and hemorrhagic events, shorter DAPT was non-inferior to longer DAPT. 3) The benefit of longer DAPT was significant in patients with first-generation DES and EES and weakened with other second-generation DES (ZES and BP-DES).
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Wei
authors.initials: W
authors.lastname: Wang
authors.affiliation: Department of Cardiology, General Hospital of Shenyang Military Area, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Jing
authors.initials: J
authors.lastname: Liu
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Jingxue
authors.initials: J
authors.lastname: Fang
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Yang
authors.initials: Y
authors.lastname: Liu
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Tong
authors.initials: T
authors.lastname: An
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China.
authors.forename: Meijuan
authors.initials: M
authors.lastname: Zou
authors.affiliation: Shenyang Pharmaceutical University, 103 Wenhua Road, Shenhe District, Shenyang, Liaoning, China. Electronic address: chenggang63@hotmail.com.
authors.forename: Gang
authors.initials: G
authors.lastname: Cheng
mesh_terms: D003324:Coronary Artery Disease / Q000628:therapy*; D054855:Drug-Eluting Stents; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000494:pharmacology*; D011183:Postoperative Complications / Q000517:prevention & control*; D011300:Preoperative Care / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D028761:Withholding Treatment / Q000592:standards / Q000706:statistics & numerical data
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: Discontinuation; Drug-eluting stents; Dual antiplatelet therapy; Meta-analysis