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Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis
Sammy Elmariah1, Laura Mauri2, Gheorghe Doros3
1Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Harvard Clinical Research Institute, Boston, MA, USA.
Insights
Extended dual antiplatelet therapy (DAPT) does not increase all-cause mortality in cardiovascular patients. This meta-analysis found no significant difference in cardiovascular or non-cardiovascular death rates with longer DAPT durations.
Area of Science:
- Cardiology
- Clinical Trials
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is standard for cardiovascular disorders.
- The impact of extended DAPT duration on overall mortality remained unclear.
- Concerns arose from the DAPT Study, suggesting increased non-cardiovascular death with prolonged treatment post-stenting.
Purpose of the Study:
- To evaluate the effect of extended DAPT duration on all-cause, cardiovascular, and non-cardiovascular mortality.
- To conduct a meta-analysis of randomized controlled trials investigating DAPT treatment duration in cardiovascular patients.
Main Methods:
- Systematic literature search of Medline, Embase, and Cochrane CENTRAL up to October 1, 2014.
- Meta-analysis using a hierarchical Bayesian random-effects model.
- Primary outcomes included hazard ratios for all-cause, cardiovascular, and non-cardiovascular death.
Main Results:
- 14 trials with 69,644 participants were included.
- Extended DAPT showed no significant difference in all-cause mortality (HR 1.05, 95% CrI 0.96-1.19) compared to aspirin alone or short-term DAPT (≤6 months).
- No significant differences were observed for cardiovascular (HR 1.01, 0.93-1.12) or non-cardiovascular mortality (HR 1.04, 0.90-1.26).
Conclusions:
- Extended duration dual antiplatelet therapy is not associated with increased risk of all-cause, cardiovascular, or non-cardiovascular death.
- Findings suggest current DAPT durations are safe regarding mortality outcomes.
- Further research may explore specific patient subgroups or bleeding risks.
Background:
Treatment with aspirin and a P2Y12 inhibitor is commonly used in patients with cardiovascular disorders. The overall effect of such treatment on all-cause mortality is unknown. In the Dual Antiplatelet Therapy (DAPT) Study, continuation of dual antiplatelet therapy beyond 12 months after coronary stenting was associated with an unexpected increase in non-cardiovascular death. In view of the potential public health importance of these findings, we aimed to assess the effect of extended duration dual antiplatelet therapy on mortality by doing a meta-analysis of all randomised, controlled trials of treatment duration in various cardiovascular disorders.
Methods:
We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomised controlled trials assessing the effect of extended duration versus no or short duration dual antiplatelet therapy, published before Oct 1, 2014. We did a meta-analysis to pool results with a hierarchical Bayesian random-effects model. The primary outcomes were hazard ratios comparing rates of all-cause, cardiovascular, and non-cardiovascular death.
Findings:
Including the DAPT Study, we identified 14 eligible trials that randomly assigned 69,644 participants to different durations of dual antiplatelet therapy. Compared with aspirin alone or short duration dual antiplatelet therapy (≤6 months), continued treatment was not associated with a difference in all-cause mortality (hazard ratio [HR] 1·05, 95% credible interval [CrI] 0·96-1·19; p=0·33). Similarly, cardiovascular (1·01, 0·93-1·12; p=0·81) and non-cardiovascular mortality (1·04, 0·90-1·26; p=0·66) were no different with extended duration versus short duration dual antiplatelet therapy or aspirin alone.
Interpretation:
Extended duration dual antiplatelet therapy was not associated with a difference in the risk of all-cause, cardiovascular, or non-cardiovascular death compared with aspirin alone or short duration dual antiplatelet therapy.
Funding:
None.
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