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Published on: May 14, 2013
Dual antiplatelet therapy duration and stent type in patients with high bleeding risk: A systematic review and
Tetsuya Saito1, Toshiki Kuno2, Tomohiro Fujisaki3
1Department of Cardiology, Edogawa Hospital, Tokyo, Japan.
Insights
For patients with high bleeding risk (HBR), short dual antiplatelet therapy (DAPT) with durable polymer drug-eluting stents (DP-DES) offers the best balance of preventing cardiovascular events and reducing bleeding. This approach is safer and effective for HBR patients undergoing percutaneous coronary intervention.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) duration and stent type impact outcomes in high bleeding risk (HBR) patients.
- Uncertainty exists regarding optimal DAPT strategies for HBR patients undergoing percutaneous coronary intervention (PCI).
Purpose of the Study:
- To determine the appropriate stent type and DAPT duration for HBR patients.
- To compare the efficacy and safety of different DAPT durations and stent types in HBR patients.
Main Methods:
- Network meta-analysis of 13 randomized controlled trials (RCTs) involving 19,418 HBR patients.
- Searched PubMed and EMBASE up to October 2023 for RCTs comparing standard DAPT (6-12 months) with short DAPT (≤3 months) using various stent types (DP-DES, BP-DES, PF-DCS, BMS).
- Primary outcomes: Major Adverse Cardiovascular Events (MACE) and major bleeding. Secondary outcomes: Myocardial Infarction (MI) and Stent Thrombosis (ST).
Main Results:
- Short DAPT with bare-metal stents (BMS) increased MACE and MI risk compared to standard DAPT with durable polymer drug-eluting stents (DP-DES).
- Short DAPT strategies significantly reduced major bleeding risk compared to standard DAPT (e.g., short DAPT with DP-DES vs. standard DAPT with DP-DES; HR: 0.48 [95% CI: 0.28-0.82]).
- Biodegradable polymer DES (BP-DES) use was linked to a higher risk of stent thrombosis (ST) than DP-DES.
Conclusions:
- A short DAPT strategy utilizing DP-DES is recommended for HBR patients.
- This strategy provides an optimal balance between cardiovascular efficacy and safety in HBR patients undergoing PCI.
- Short DAPT with DP-DES minimizes bleeding risk while maintaining adequate protection against MACE and MI.
Background:
It is uncertain whether the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with high bleeding risk (HBR) vary according to DAPT duration and stent type (eg, durable polymer drug-eluting stents (DP-DESs), biodegradable polymer DESs (BP-DESs), or polymer-free drug-coated stents (PF-DCSs)). We aimed to study the stent type and DAPT duration appropriate for patients with HBR.
Methods:
PubMed and EMBASE were searched until October 2023. Randomized controlled trials (RCTs) involving patients with HBR that compared standard DAPT (6-12 months) with DP- or BP-DES versus short DAPT (≤3 months) with DP- or BP-DES or PF-DCS or bare-metal stent (BMS) were identified. The primary efficacy outcome was major adverse cardiovascular events (MACEs), defined as cardiovascular death, myocardial infarction (MI), and stroke. The primary safety outcome was major bleeding. Secondary outcomes included MI and stent thrombosis (ST). We performed a network meta-analysis using a random effects model.
Results:
Thirteen RCTs with a total of 19,418 patients with HBR were included. Compared to standard DAPT with DP-DES, short DAPT with BMS was associated with a higher risk of MACE and MI. For major bleeding, short DAPT strategies were associated with a lower risk than standard DAPT strategies (e.g. short DAPT with DP-DES vs standard DAPT with DP-DES; HR[95% CI]: 0.48[0.28-0.82]). Interestingly, the use of BP-DES was associated with a higher risk of ST than DP-DES (e.g. standard DAPT with BP-DES vs short DAPT with DP-DES; HR[95% CI]: 2.65[1.03-6.79]).
Conclusions:
In patients with HBR who underwent percutaneous coronary intervention, a short DAPT strategy with DP-DES should be used since it offers the best combination of efficacy and safety.
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