Extended Duration Dual Antiplatelet Therapy and Mortality: A Systematic Review and Meta-Analysis

Abstract

Background-Treatment with the combination of aspirin and a P2Y12 inhibitor is commonly employed in a number of cardiovascular conditions. The overall impact of such treatment on allcause mortality is unknown. In the Dual Antiplatelet Therapy (DAPT) Study, an international multicenter randomized placebo-controlled trial comparing 30 versus 12 months of dual antiplatelet therapy after coronary stenting, continuation of DAPT beyond 12 months was associated with an increase in mortality at trial completion, largely attributable to an increase in non-cardiovascular death. Given the potential public health importance of this, we performed a meta-analysis of all randomized, controlled trials of DAPT duration across a wide array of cardiovascular conditions to evaluate the impact of extended duration DAPT on mortality.

Percutaneous Coronary Intervention: 2015 in Review

“…[86][87] Although many authors expressed concern about increased mortality with prolonged DAPT, another meta-analysis which included a diverse population of 70,000 patients with atrial fibrillation, peripheral vascular, cerebrovascular disease or coronary disease, did not find an increase in mortality with extended duration of DAPT. 89 Should we find this reassuring? We are disappointed that this metaanalysis showed no mortality advantage despite 70,000 randomized patients randomized.…”

“…Potential Clinical Implications Zeus 15 and LEADERS FREE 16 Avoid bare metal stents in patients at high risk of bleeding. 30 days of DAPT with newer generation DES superior to BMS ABSORB II and III 24,25 Avoid BVS in vessels <2.25 diameter Kim et al 40 Avoid final kissing balloon in bifucations without significant disease in side branch CvLPRIT 58 , DANAMI-3 60 , PRAGUE-13 61 , EXPLORE Staged complete revascularization in the STEMI patient with multivessel disease may be safely performed but does not reduce hard endpoints Stub et al 67 AVOID routine supplimental oxygen in STEMI patients Numerous studies 15,16,[85][86][87][88][89][90][91][92] Individualize the duration of DAPT based on patient procedural risk factors for stent thrombosis MATRIX 28 Use radial access to reduce bleeding and improve survival in ACS patients MATRIX 96 Use bivalirudin to reduce bleeding and improve survival in ACS patients Carson 106 , Murphy 107 Blood transfusions are not harmful to the cardiac patient, and may improved prognosis after cardiac surgery Not surprisingly, they were used in higher risk patients, thus acute complications were increased. Long term follow-up, obtained by linking to Medicare claims data, showed similar risk adjusted death, MI and revascularization.…”

Clinical Outcome of First‐ vs Second‐Generation DES According to DAPT Duration: Results of ARCTIC‐Generation

“…9 Extended-duration dual antiplatelet therapy (DAPT) prevents atherothrombotic events in patients with symptomatic vascular disease, 10,11 with a significant increased risk of major bleeding and a neutral effect on cardiovascular and noncardiovascular mortality. 12 Duration of DAPT after coronary stenting remains a matter of debate. The susceptibility of first-generation DES to ST, due to delayed vessel healing, polymer hypersensitivity, and other mechanisms, led to the recommendation of prolonged DAPT.…”

Dual antiplatelet therapy after stroke or transient ischaemic attack – how long to treat? The duration of aspirin plus clopidogrel in stroke or transient ischaemic attack: a systematic review and meta‐analysis

“…However, whether the duration of 90 days' DAPT is optimal for each patient remains unclear. Several previous trials and meta-analyses in ischaemic heart diseases have shown that DAPT beyond 1 year significantly reduced the risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events after myocardial infarction and placement of a drug-eluting stent [14][15][16][17]. Recently, 1-year follow-up of the CHANCE study showed a continued efficacy with short-term DAPT [18].…”