Author + information
- Received December 18, 2014
- Revision received January 16, 2015
- Accepted January 20, 2015
- Published online April 7, 2015.
- Gennaro Giustino, MD∗,
- Usman Baber, MD∗,
- Samantha Sartori, PhD∗,
- Roxana Mehran, MD∗,
- Ioannis Mastoris, MD∗,
- Annapoorna S. Kini, MD∗,
- Samin K. Sharma, MD∗,
- Stuart J. Pocock, PhD† and
- George D. Dangas, MD, PhD∗∗ ()
- ∗The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- †Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. George D. Dangas, Division of Cardiology, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, New York 10029.
Background The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is unclear, and its risks and benefits may vary according to DES generation.
Objectives The goal of this study was to evaluate the efficacy and safety of DAPT after DES implantation.
Methods We included randomized controlled trials that tested different durations of DAPT after DES implantation: shorter dual antiplatelet therapy (S-DAPT) was defined as the per-protocol minimum duration of DAPT after the procedure, and longer dual antiplatelet therapy (L-DAPT) was defined as the per-protocol period of more prolonged DAPT. The primary efficacy and safety outcomes were definite/probable stent thrombosis and clinically significant bleeding (CSB), respectively.
Results Ten randomized controlled trials (N = 32,135) were included. Compared with L-DAPT, S-DAPT had an overall higher rate of stent thrombosis (odds ratio [OR]: 1.71 [95% confidence interval (CI): 1.26 to 2.32]; p = 0.001). The effect of S-DAPT on stent thrombosis was attenuated with the use of second-generation DES (OR: 1.54 [95% CI: 0.96 to 2.47]) compared with the use of first-generation DES (OR: 3.94 [95% CI: 2.20 to 7.05]; p for interaction = 0.008). S-DAPT had an overall significantly lower risk of CSB (OR: 0.63 [95% CI: 0.52 to 0.75]; p < 0.001). Finally, a numerically lower all-cause mortality rate was observed with S-DAPT (OR: 0.87 [95% CI: 0.74 to 1.01]; p = 0.073).
Conclusions S-DAPT had overall lower rates of bleeding yet higher rates of stent thrombosis compared with L-DAPT; the latter effect was significantly attenuated with the use of second-generation DES, although the analysis may have been limited by the varying DAPT durations among studies. All-cause mortality was numerically higher with L-DAPT without reaching statistical significance. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications.
Dr. Mehran is a consultant for AstraZeneca, Bayer, CSL Behring, Janssen Pharmaceuticals Inc., Merck & Co. Inc., Osprey Medical Inc., Regado Biosciences Inc., The Medicines Company, and Watermark Consulting; and is on the scientific advisory board of Abbott Laboratories, AstraZeneca, Boston Scientific Corporation, Covidien, Janssen Pharmaceuticals Inc., Merck & Co. Inc., The Medicines Company, and Sanofi. Dr. Dangas is a consultant for GE HealthCare, Janssen Pharmaceuticals Inc., and Medtronic; and is on the scientific advisory board of AstraZeneca. Dr. Pocock has received research grants from GlaxoSmithKline, The Medicines Company, Pfizer, Edwards Lifesciences, Biosensors, Amgen, Boston Scientific, AstraZeneca, and Janssen. Dr. Sharma is on the scientific advisory board of Cardiovascular Systems Inc.; and serves on the Speakers Bureaus of Abbott Vascular, Angioscore, Boston Scientific, Lilly/Daiichi Sankyo, and The Medicines Company. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Sanjay Kaul, MD, served as Guest Editor for this paper.
- Received December 18, 2014.
- Revision received January 16, 2015.
- Accepted January 20, 2015.
- 2015 American College of Cardiology Foundation