Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a network meta-analysis

Abstract

Introduction: Although the recommended duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation has been shortened in the current guidelines, the optimal duration is as controversial as ever. We therefore performed a network meta-analysis incorporating the latest trials to assess the risks and benefits of different DAPT durations. Methods: We searched for randomised controlled trials (RCTs) comparing different DAPT durations after drugeluting stent implantation and reporting frequencies of cardiovascular and bleeding events. Data analysis was performed using R statistics. Results: Fifteen RCTs with altogether 42 317 patients were finally included. Extended DAPT (>12 months) significantly reduced the frequencies of myocardial infarction (odds ratio [OR]=0.54, 95% confidence interval [CI]=0.44-0.65 and OR=0.54, 95% CI=0.41-0.70), and stent thrombosis (OR=0.43, 95% CI=0.29-0.63 and OR=0.51, 95% CI=0.33-0.78) when compared with 12-month and short-term DAPT (<12 months), respectively. However, the risk of major bleeding (OR=1.47, 95% CI=1.17-1.85 and OR=2.03, 95% CI=1.40-2.94) and all-cause mortality (OR=1.27, 95% CI=1.03-1.56 and OR=1.30, 95% CI=1.04-1.62) was substantially increased when compared with 12-month and short-term DAPT, respectively. No significant difference was found in cardiovascular mortality, stroke, and repeat revascularisation. Conclusion: Extended DAPT has the lowest rate of myocardial infarction and stent thrombosis, but the highest risk of major bleeding and all-cause mortality. Clinical trial evidence favours short-term more than extended DAPT because of increased mortality. Duration of DAPT should be individualised according to the risk–benefit profile of each patient.