Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and network meta-analysis of randomised controlled trials

Abstract

Background The optimal duration of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation remains uncertain. Despite recent studies, direct comparison between short-term (<12 months) and extended (>12 months) DAPT is limited. We performed a network meta-analysis to assess the risk of mortality and other cardiovascular outcomes with different DAPT durations in order to guide clinical practice. Methods We searched for randomised controlled trials comparing different durations of DAPT after DES implantation. Those reporting frequencies of cardiovascular and bleeding events were eligible to be included. Statistic analysis was performed using frequentist approach and Bayesian framework in R. Results We included 12 randomised controlled trials with altogether 34920 patients for analysis. Extended DAPT (>12 months) significantly lowered the risk of myocardial infarction (OR 0.56, 95%CI 0.46-0.68 and 0.58, 0.44-0.77), and stent thrombosis (0.44, 0.30-0.65 and 0.49, 0.29-0.82) when compared to 12-month and short-term DAPT (<12 months), respectively. However, it was associated with increased major bleeding (1.53, 1.21-1.93 and 2.58, 1.62-4.10). Compared to 12-month DAPT, extended DAPT had more all-cause death (1.27, 1.03-1.57); short-term DAPT had less major bleeds (0.59, 0.39-0.91). Conclusions Although extending DAPT beyond 12 months after DES implantation reduced myocardial infarction and stent thrombosis, the risk of major bleeding and all-cause mortality was substantially increased. No clear superiority of extended or short-term DAPT over 12-month DAPT was identified. DAPT duration should always be tailored for different patients after considering their benefit-risk profiles.