Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients

Tullio Palmerini, Antonio G. Bruno, Martine Gilard, Marie Claude Morice, Marco Valgimigli, Gilles Montalescot, Jean Philippe Collet, Diego Della Riva, Maria Letizia Bacchi-Reggiani, Philippe Gabriel Steg, Abdourahmane Diallo, Eric Vicaut, Gerard Helft, Masato Nakamura, Philippe Généreux, Torsten P. Vahl, Gregg W. Stone

Research output: Contribution to journalArticle

Abstract

BACKGROUND: We sought to determine whether the risks and benefits of prolonging dual-antiplatelet therapy (DAPT) beyond 1 year after drug-eluting stent implantation depend on clinical presentation in a meta-analysis of randomized controlled trials. METHODS AND RESULTS: Randomized controlled trials comparing ≤1-versus >1-year DAPT after drug-eluting stent placement were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary efficacy end point was myocardial infarction, whereas the primary safety end point was major bleeding. Net clinical benefit was defined as the composite of myocardial infarction or major bleeding. Outcomes were analyzed according to patient presentation with stable ischemic heart disease versus acute coronary syndromes. The meta-analysis included 6 trials with a total of 21457 patients, including 14132 with stable ischemic heart disease and 7325 with acute coronary syndrome. After a median follow-up of 19.5 months, ≤1-year DAPT was associated with higher rates of myocardial infarction compared with >1-year DAPT (hazard ratio [HR], 1.63; 95% CI, 1.37-1.95), with no interaction apparent between treatment effect and clinical presentation. Shorter DAPT was associated with reduced rates of major bleeding compared with longer DAPT (HR, 0.64; 95% CI, 0.42-0.99) with no significant interaction between treatment effect and clinical presentation. However, a net clinical benefit of >1-year DAPT was present in patients with acute coronary syndrome (HR of shorter versus longer DAPT, 1.59; 95% CI, 1.24-2.02) but not in those with stable ischemic heart disease (HR, 1.15; 95% CI, 0.89-1.51; Pinteraction=0.04). Shorter DAPT was also associated with lower rates of noncardiac mortality compared with longer DAPT (HR, 0.71; 95% CI, 0.52-0.96), with no significant interaction between treatment effect and clinical presentation (Pinteraction=0.12). CONCLUSIONS: Compared with ≤1-year DAPT, >1-year DAPT reduces the risk of myocardial infarction but increases the risk of major bleeding and noncardiac mortality. A net clinical benefit of extended DAPT was apparent for patients with acute coronary syndrome but not for those with stable ischemic heart disease.

Original languageEnglish (US)
Article numbere007541
JournalCirculation: Cardiovascular Interventions
Volume12
Issue number3
DOIs
StatePublished - Jan 1 2019

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Drug-Eluting Stents
Meta-Analysis
Therapeutics
Acute Coronary Syndrome
Myocardial Ischemia
Myocardial Infarction
Hemorrhage
Randomized Controlled Trials
Mortality
MEDLINE

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Palmerini, Tullio ; Bruno, Antonio G. ; Gilard, Martine ; Morice, Marie Claude ; Valgimigli, Marco ; Montalescot, Gilles ; Collet, Jean Philippe ; Della Riva, Diego ; Bacchi-Reggiani, Maria Letizia ; Steg, Philippe Gabriel ; Diallo, Abdourahmane ; Vicaut, Eric ; Helft, Gerard ; Nakamura, Masato ; Généreux, Philippe ; Vahl, Torsten P. ; Stone, Gregg W. / Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients. In: Circulation: Cardiovascular Interventions. 2019 ; Vol. 12, No. 3.
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abstract = "BACKGROUND: We sought to determine whether the risks and benefits of prolonging dual-antiplatelet therapy (DAPT) beyond 1 year after drug-eluting stent implantation depend on clinical presentation in a meta-analysis of randomized controlled trials. METHODS AND RESULTS: Randomized controlled trials comparing ≤1-versus >1-year DAPT after drug-eluting stent placement were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary efficacy end point was myocardial infarction, whereas the primary safety end point was major bleeding. Net clinical benefit was defined as the composite of myocardial infarction or major bleeding. Outcomes were analyzed according to patient presentation with stable ischemic heart disease versus acute coronary syndromes. The meta-analysis included 6 trials with a total of 21457 patients, including 14132 with stable ischemic heart disease and 7325 with acute coronary syndrome. After a median follow-up of 19.5 months, ≤1-year DAPT was associated with higher rates of myocardial infarction compared with >1-year DAPT (hazard ratio [HR], 1.63; 95{\%} CI, 1.37-1.95), with no interaction apparent between treatment effect and clinical presentation. Shorter DAPT was associated with reduced rates of major bleeding compared with longer DAPT (HR, 0.64; 95{\%} CI, 0.42-0.99) with no significant interaction between treatment effect and clinical presentation. However, a net clinical benefit of >1-year DAPT was present in patients with acute coronary syndrome (HR of shorter versus longer DAPT, 1.59; 95{\%} CI, 1.24-2.02) but not in those with stable ischemic heart disease (HR, 1.15; 95{\%} CI, 0.89-1.51; Pinteraction=0.04). Shorter DAPT was also associated with lower rates of noncardiac mortality compared with longer DAPT (HR, 0.71; 95{\%} CI, 0.52-0.96), with no significant interaction between treatment effect and clinical presentation (Pinteraction=0.12). CONCLUSIONS: Compared with ≤1-year DAPT, >1-year DAPT reduces the risk of myocardial infarction but increases the risk of major bleeding and noncardiac mortality. A net clinical benefit of extended DAPT was apparent for patients with acute coronary syndrome but not for those with stable ischemic heart disease.",
author = "Tullio Palmerini and Bruno, {Antonio G.} and Martine Gilard and Morice, {Marie Claude} and Marco Valgimigli and Gilles Montalescot and Collet, {Jean Philippe} and {Della Riva}, Diego and Bacchi-Reggiani, {Maria Letizia} and Steg, {Philippe Gabriel} and Abdourahmane Diallo and Eric Vicaut and Gerard Helft and Masato Nakamura and Philippe G{\'e}n{\'e}reux and Vahl, {Torsten P.} and Stone, {Gregg W.}",
year = "2019",
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day = "1",
doi = "10.1161/CIRCINTERVENTIONS.118.007541",
language = "English (US)",
volume = "12",
journal = "Circulation: Cardiovascular Interventions",
issn = "1941-7640",
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Palmerini, T, Bruno, AG, Gilard, M, Morice, MC, Valgimigli, M, Montalescot, G, Collet, JP, Della Riva, D, Bacchi-Reggiani, ML, Steg, PG, Diallo, A, Vicaut, E, Helft, G, Nakamura, M, Généreux, P, Vahl, TP & Stone, GW 2019, 'Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients', Circulation: Cardiovascular Interventions, vol. 12, no. 3, e007541. https://doi.org/10.1161/CIRCINTERVENTIONS.118.007541

Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients. / Palmerini, Tullio; Bruno, Antonio G.; Gilard, Martine; Morice, Marie Claude; Valgimigli, Marco; Montalescot, Gilles; Collet, Jean Philippe; Della Riva, Diego; Bacchi-Reggiani, Maria Letizia; Steg, Philippe Gabriel; Diallo, Abdourahmane; Vicaut, Eric; Helft, Gerard; Nakamura, Masato; Généreux, Philippe; Vahl, Torsten P.; Stone, Gregg W.

In: Circulation: Cardiovascular Interventions, Vol. 12, No. 3, e007541, 01.01.2019.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Risk-benefit profile of longer-than-1-year dual-antiplatelet therapy duration after drug-eluting stent implantation in relation to clinical presentation a pairwise meta-analysis of 6 trials and 21 457 patients

AU - Palmerini, Tullio

AU - Bruno, Antonio G.

AU - Gilard, Martine

AU - Morice, Marie Claude

AU - Valgimigli, Marco

AU - Montalescot, Gilles

AU - Collet, Jean Philippe

AU - Della Riva, Diego

AU - Bacchi-Reggiani, Maria Letizia

AU - Steg, Philippe Gabriel

AU - Diallo, Abdourahmane

AU - Vicaut, Eric

AU - Helft, Gerard

AU - Nakamura, Masato

AU - Généreux, Philippe

AU - Vahl, Torsten P.

AU - Stone, Gregg W.

PY - 2019/1/1

Y1 - 2019/1/1

N2 - BACKGROUND: We sought to determine whether the risks and benefits of prolonging dual-antiplatelet therapy (DAPT) beyond 1 year after drug-eluting stent implantation depend on clinical presentation in a meta-analysis of randomized controlled trials. METHODS AND RESULTS: Randomized controlled trials comparing ≤1-versus >1-year DAPT after drug-eluting stent placement were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary efficacy end point was myocardial infarction, whereas the primary safety end point was major bleeding. Net clinical benefit was defined as the composite of myocardial infarction or major bleeding. Outcomes were analyzed according to patient presentation with stable ischemic heart disease versus acute coronary syndromes. The meta-analysis included 6 trials with a total of 21457 patients, including 14132 with stable ischemic heart disease and 7325 with acute coronary syndrome. After a median follow-up of 19.5 months, ≤1-year DAPT was associated with higher rates of myocardial infarction compared with >1-year DAPT (hazard ratio [HR], 1.63; 95% CI, 1.37-1.95), with no interaction apparent between treatment effect and clinical presentation. Shorter DAPT was associated with reduced rates of major bleeding compared with longer DAPT (HR, 0.64; 95% CI, 0.42-0.99) with no significant interaction between treatment effect and clinical presentation. However, a net clinical benefit of >1-year DAPT was present in patients with acute coronary syndrome (HR of shorter versus longer DAPT, 1.59; 95% CI, 1.24-2.02) but not in those with stable ischemic heart disease (HR, 1.15; 95% CI, 0.89-1.51; Pinteraction=0.04). Shorter DAPT was also associated with lower rates of noncardiac mortality compared with longer DAPT (HR, 0.71; 95% CI, 0.52-0.96), with no significant interaction between treatment effect and clinical presentation (Pinteraction=0.12). CONCLUSIONS: Compared with ≤1-year DAPT, >1-year DAPT reduces the risk of myocardial infarction but increases the risk of major bleeding and noncardiac mortality. A net clinical benefit of extended DAPT was apparent for patients with acute coronary syndrome but not for those with stable ischemic heart disease.

AB - BACKGROUND: We sought to determine whether the risks and benefits of prolonging dual-antiplatelet therapy (DAPT) beyond 1 year after drug-eluting stent implantation depend on clinical presentation in a meta-analysis of randomized controlled trials. METHODS AND RESULTS: Randomized controlled trials comparing ≤1-versus >1-year DAPT after drug-eluting stent placement were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary efficacy end point was myocardial infarction, whereas the primary safety end point was major bleeding. Net clinical benefit was defined as the composite of myocardial infarction or major bleeding. Outcomes were analyzed according to patient presentation with stable ischemic heart disease versus acute coronary syndromes. The meta-analysis included 6 trials with a total of 21457 patients, including 14132 with stable ischemic heart disease and 7325 with acute coronary syndrome. After a median follow-up of 19.5 months, ≤1-year DAPT was associated with higher rates of myocardial infarction compared with >1-year DAPT (hazard ratio [HR], 1.63; 95% CI, 1.37-1.95), with no interaction apparent between treatment effect and clinical presentation. Shorter DAPT was associated with reduced rates of major bleeding compared with longer DAPT (HR, 0.64; 95% CI, 0.42-0.99) with no significant interaction between treatment effect and clinical presentation. However, a net clinical benefit of >1-year DAPT was present in patients with acute coronary syndrome (HR of shorter versus longer DAPT, 1.59; 95% CI, 1.24-2.02) but not in those with stable ischemic heart disease (HR, 1.15; 95% CI, 0.89-1.51; Pinteraction=0.04). Shorter DAPT was also associated with lower rates of noncardiac mortality compared with longer DAPT (HR, 0.71; 95% CI, 0.52-0.96), with no significant interaction between treatment effect and clinical presentation (Pinteraction=0.12). CONCLUSIONS: Compared with ≤1-year DAPT, >1-year DAPT reduces the risk of myocardial infarction but increases the risk of major bleeding and noncardiac mortality. A net clinical benefit of extended DAPT was apparent for patients with acute coronary syndrome but not for those with stable ischemic heart disease.

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