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

Abstract

Introduction: Although there is a trend of recommending shorter duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation, the optimal duration is as controversial as ever. We performed a network meta-analysis incorporating the latest trials to assess the risks and benefits of different DAPT durations. Methods: Randomised controlled trials (RCTs) comparing different DAPT durations after DES implantation and reporting frequencies of cardiovascular and bleeding events were searched up to 30 June 2019. Data analysis was performed using R statistics. Results: Seventeen RCTs with altogether 46 684 patients were finally included. Extended DAPT significantly reduced the incidence of myocardial infarction and definite/probable stent thrombosis compared with 12-month DAPT (odds ratio [OR]=0.54, 95% confidence interval [CI]=0.45-0.66, P<0.001 and OR=0.47, 95% CI=0.32-0.69, P<0.001), and short-term DAPT (OR=0.52, 95% CI=0.41-0.67, P<0.001 and OR=0.47, 95% CI=0.31-0.72, P<0.001), respectively. Short-term DAPT increased the risk of repeat revascularisation (OR=1.23, 95% CI=1.06-1.43, P=0.006) compared with 12-month DAPT. In contrast, extended DAPT resulted in more major bleeds than short-term DAPT (OR=2.00, 95% CI=1.36-2.92, P<0.001) and 12-month DAPT (OR=1.43, 95% CI=1.07-1.91, P=0.016). Conclusion: Extended DAPT over 12 months, if well tolerated, decreases myocardial infarction and stent thrombosis but increases major bleeds. Short-term DAPT should be considered for most patients after DES implantation; however, the possibility of increased repeat revascularisation should not be ignored. The optimal DAPT therapy should therefore be individualised after weighing up the bleeding risk and ischaemic benefits for that patient.