Short- Versus Standard-Duration Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Acute Coronary...

Dual antiplatelet therapy (DAPT) for 12 months has historically been the standard of care following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS); however, prolonged DAPT carries a cumulative, time-dependent risk of major bleeding. We aimed to determine whether a short DAPT duration (≤6 months) followed by single antiplatelet therapy reduces bleeding events without compromising ischemic safety compared with standard 12-month DAPT in ACS patients. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) by searching Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), and Cochrane Controlled Register of Trials (CENTRAL) from inception to March 2026 for studies comparing short DAPT (≤6 months) versus standard DAPT (12 months) in adults undergoing PCI with drug-eluting stents for ACS. The co-primary endpoints were major bleeding and major adverse cardiovascular events (MACE), defined as a composite of death, myocardial infarction (MI), and stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using a DerSimonian-Laird random-effects model, with pre-specified subgroup analyses according to the type of P2Y12 inhibitor used during the monotherapy phase. Seven RCTs comprising 23,586 patients were included. Compared with standard 12-month DAPT, short DAPT significantly reduced the risk of major bleeding by 40% (HR 0.60, 95% CI 0.49-0.73; p<0.001), without a statistically significant increase in MACE (HR 1.02, 95% CI 0.88-1.17; p=0.79), all-cause mortality (HR 0.96, 95% CI 0.80-1.14; p=0.66), or stroke (HR 0.91, 95% CI 0.70-1.17; p=0.46). Subgroup analysis demonstrated a significant interaction by P2Y12 inhibitor type for MI (p=0.016) and MACE (p=0.033), whereby early transition to clopidogrel monotherapy was associated with an approximately two-fold increase in MI risk, whereas monotherapy with a potent P2Y12 inhibitor (e.g., ticagrelor) preserved ischemic safety without excess events. In conclusion, in patients with ACS undergoing PCI, abbreviated DAPT (≤6 months) optimizes net clinical benefit by substantially reducing major bleeding without increasing overall ischemic or mortality risk; however, this safety is critically dependent on the choice of maintenance antiplatelet agent, with potent P2Y12 inhibitor monotherapy representing a safe strategy and early de-escalation to clopidogrel conferring excess MI risk.