Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes

An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients

Tullio Palmerini, Diego Della Riva, Umberto Benedetto, Bletizia Bacchi Reggiani, Fausto Feres, Alexandre Abizaid, Martine Gilard, Marie Claude Morice, Marco Valgimigli, Myeong Ki Hong, Byeong Keuk Kim, Yangsoo Jang, Hyo Soo Kim, Kyung Woo Park, Antonio Colombo, Alaide Chieffo, Diego Sangiorgi, Giuseppe Biondi-Zoccai, Philippe Genereux, Gianni D. Angelini & 4 others Maria Pufulete, Jonathon White, Deepak L. Bhatt, Gregg W. Stone

Research output: Contribution to journalArticle

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Abstract

Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.

Original languageEnglish (US)
Pages (from-to)1034-1043
Number of pages10
JournalEuropean Heart Journal
Volume38
Issue number14
DOIs
StatePublished - Jan 1 2017

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Acute Coronary Syndrome
Drug-Eluting Stents
Therapeutics
Stents
Thrombosis
Network Meta-Analysis
clopidogrel
Hemorrhage
Myocardial Infarction
Confidence Intervals
Unstable Angina
Aspirin

All Science Journal Classification (ASJC) codes

  • Cardiology and Cardiovascular Medicine

Cite this

Palmerini, Tullio ; Della Riva, Diego ; Benedetto, Umberto ; Reggiani, Bletizia Bacchi ; Feres, Fausto ; Abizaid, Alexandre ; Gilard, Martine ; Morice, Marie Claude ; Valgimigli, Marco ; Hong, Myeong Ki ; Kim, Byeong Keuk ; Jang, Yangsoo ; Kim, Hyo Soo ; Park, Kyung Woo ; Colombo, Antonio ; Chieffo, Alaide ; Sangiorgi, Diego ; Biondi-Zoccai, Giuseppe ; Genereux, Philippe ; Angelini, Gianni D. ; Pufulete, Maria ; White, Jonathon ; Bhatt, Deepak L. ; Stone, Gregg W. / Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes : An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. In: European Heart Journal. 2017 ; Vol. 38, No. 14. pp. 1034-1043.
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title = "Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes: An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients",
abstract = "Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5{\%}) had stable CAD and 4758 (41.5{\%}) presented with acute coronary syndrome (ACS), the majority of whom (67.0{\%}) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95{\%} Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95{\%}CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.",
author = "Tullio Palmerini and {Della Riva}, Diego and Umberto Benedetto and Reggiani, {Bletizia Bacchi} and Fausto Feres and Alexandre Abizaid and Martine Gilard and Morice, {Marie Claude} and Marco Valgimigli and Hong, {Myeong Ki} and Kim, {Byeong Keuk} and Yangsoo Jang and Kim, {Hyo Soo} and Park, {Kyung Woo} and Antonio Colombo and Alaide Chieffo and Diego Sangiorgi and Giuseppe Biondi-Zoccai and Philippe Genereux and Angelini, {Gianni D.} and Maria Pufulete and Jonathon White and Bhatt, {Deepak L.} and Stone, {Gregg W.}",
year = "2017",
month = "1",
day = "1",
doi = "10.1093/eurheartj/ehw627",
language = "English (US)",
volume = "38",
pages = "1034--1043",
journal = "European Heart Journal",
issn = "0195-668X",
publisher = "Oxford University Press",
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Palmerini, T, Della Riva, D, Benedetto, U, Reggiani, BB, Feres, F, Abizaid, A, Gilard, M, Morice, MC, Valgimigli, M, Hong, MK, Kim, BK, Jang, Y, Kim, HS, Park, KW, Colombo, A, Chieffo, A, Sangiorgi, D, Biondi-Zoccai, G, Genereux, P, Angelini, GD, Pufulete, M, White, J, Bhatt, DL & Stone, GW 2017, 'Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes: An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients', European Heart Journal, vol. 38, no. 14, pp. 1034-1043. https://doi.org/10.1093/eurheartj/ehw627

Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes : An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. / Palmerini, Tullio; Della Riva, Diego; Benedetto, Umberto; Reggiani, Bletizia Bacchi; Feres, Fausto; Abizaid, Alexandre; Gilard, Martine; Morice, Marie Claude; Valgimigli, Marco; Hong, Myeong Ki; Kim, Byeong Keuk; Jang, Yangsoo; Kim, Hyo Soo; Park, Kyung Woo; Colombo, Antonio; Chieffo, Alaide; Sangiorgi, Diego; Biondi-Zoccai, Giuseppe; Genereux, Philippe; Angelini, Gianni D.; Pufulete, Maria; White, Jonathon; Bhatt, Deepak L.; Stone, Gregg W.

In: European Heart Journal, Vol. 38, No. 14, 01.01.2017, p. 1034-1043.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Three, six, or twelve months of dual antiplatelet therapy after des implantation in patients with or without acute coronary syndromes

T2 - An individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients

AU - Palmerini, Tullio

AU - Della Riva, Diego

AU - Benedetto, Umberto

AU - Reggiani, Bletizia Bacchi

AU - Feres, Fausto

AU - Abizaid, Alexandre

AU - Gilard, Martine

AU - Morice, Marie Claude

AU - Valgimigli, Marco

AU - Hong, Myeong Ki

AU - Kim, Byeong Keuk

AU - Jang, Yangsoo

AU - Kim, Hyo Soo

AU - Park, Kyung Woo

AU - Colombo, Antonio

AU - Chieffo, Alaide

AU - Sangiorgi, Diego

AU - Biondi-Zoccai, Giuseppe

AU - Genereux, Philippe

AU - Angelini, Gianni D.

AU - Pufulete, Maria

AU - White, Jonathon

AU - Bhatt, Deepak L.

AU - Stone, Gregg W.

PY - 2017/1/1

Y1 - 2017/1/1

N2 - Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.

AB - Aim We sought to determine whether theoptimal dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) placement varies according to clinical presentation. Methods and Results We performed an individual patient data pairwise and network meta-analysis comparing short-term (≤6-months) versus long-term (1-year) DAPT as well as 3-month vs. 6-month vs 1-year DAPT. The primary studyoutcome was the 1- year composite risk of myocardial infarction (MI)or definite/probable stent thrombosis (ST). Six trials were included in which DAPT after DES consisted of aspirin and clopidogrel. Among 11 473 randomized patients 6714 (58.5%) had stable CAD and 4758 (41.5%) presented with acute coronary syndrome (ACS), the majority of whom (67.0%) had unstable angina. In ACS patients, ≤6-month DAPT was associated with non-significantly higher 1-year rates of MIor ST compared with 1-year DAPT (Hazard Ratio (HR) 1.48, 95% Confidence interval (CI) 0.98-2.22; P = 0.059), whereas in stable patients rates of MI and ST were similar between the two DAPT strategies (HR 0.93, 95%CI 0.65-1.35; P=0.71; Pinteraction=0.09). By network meta-analysis, 3-month DAPT, but not 6-month DAPT, was associated with higher rates of MIor ST in ACS, whereas no significant differences were apparent in stable patients. Short DAPT was associated with lower rates of major bleeding compared with 1-year DAPT, irrespective of clinical presentation. All-cause mortality was not significantly different with short vs. long DAPT in both patients with stable CAD and ACS. Conclusions Optimal DAPT duration after DES differs according to clinical presentation. In the present meta-analysis, despite the fact that most enrolled ACS patients were relatively low risk, 3-month DAPT was associated with increased ischaemic risk, whereas 3-month DAPT appeared safe in stable CAD. Prolonged DAPT increases bleeding regardless of clinical presentation. Further study is required to identify theoptimal duration of DAPT after DES in individual patients basedon their relative ischaemic and bleeding risks.

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DO - 10.1093/eurheartj/ehw627

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EP - 1043

JO - European Heart Journal

JF - European Heart Journal

SN - 0195-668X

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