Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials

Palmerini, Tullio; Benedetto, Umberto; Reggiani, Maria Letizia Bacchi; Riva, Diego Della; Biondi‐Zoccai, Giuseppe; Feres, Fausto; Abizaid, Alexandre; Hong, Myeong Ki; Kim, Byeong Keuk; Jang, Yangsoo; Kim, Hyo Soo; Park, Kyung Woo; Généreux, Philippe; Bhatt, Deepak L.; Orlandi, C; Servi, Stefano De; Petrou, Mario; Rapezzi, Claudio; Stone, Gregg W.

doi:10.1016/s0140-6736(15)60263-x

Cited by 357 publications

(252 citation statements)

References 29 publications

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“…Importantly, we did not observe the increased signal of all-cause mortality seen in the DAPT trial [9] or in a previous meta-analysis [21]. Increased all-cause mortality has been partly attributed to the observed higher risk of major bleeding with prolonged use of DAPT [9].…”

Section: Resultscontrasting

confidence: 75%

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Sharma

Agrawal

Garg

et al. 2017

Cathet Cardio Intervent

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Objective To evaluate the long term efficacy and safety of long duration DAPT (L‐DAPT) compared to short duration DAPT (S‐DAPT) after drug‐eluting stent (DES) implantation. Methods We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the clinical impact of L‐DAPT versus S‐DAPT after DES and have mean follow up period of at least 2 years or longer. Primary end point was stent thrombosis (ST). Secondary endpoints were all‐cause mortality, cardiac mortality, myocardial infarction (MI), target vessel revascularization (TVR), thrombolysis in myocardial infarction (TIMI) major bleeding and stroke. Event rates were compared using a random effects model. Results We identified five RCTs in which 19,760 patients were randomized to S‐DAPT (N = 9,810) and L‐DAPT (n = 9,950), respectively. Compared with L‐DAPT, S‐DAPT was associated with higher rate of MI (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.04, 2.10]). There were no significant differences between S‐DAPT and L‐DAPT in terms of all cause mortality, cardiac mortality, ST, TVR or stroke (OR 0.90, 95% CI [0.73, 1.12]; OR 1.02, 95% CI [0.80, 1.30]; OR 1.59, 95% CI [0.77, 3.27]; OR 0.87 95% CI [0.67, 1.14]; and OR 1.08 95% CI [0.81, 1.46], respectively). However, rate of TIMI major bleeding was significantly lower with S‐DAPT compared to L‐DAPT (OR 0.64, 95% CI [0.41, 0.99]). Conclusions In the present analysis of RCTs with longer follow up (2 years or longer), S‐DAPT compared with L‐DAPT, was associated with higher rate of MI and lower rate of major bleeding without any significant difference in the rates of all cause mortality, cardiac mortality, ST, TVR, and stroke.

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Section: Resultscontrasting

confidence: 75%

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Sharma

Agrawal

Garg

et al. 2017

Cathet Cardio Intervent

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“…Recently, two large randomised trials, DAPT and PEGASUS-TIMI 54 (Prevention of cardiovascular events in patients with prior heart attack using ticagrelor compared to placebo on a background of aspirin-thrombolysis in myocardial infarction 54), showed a significant reduction in ischaemic events with long-term DAPT among patients undergoing PCI as well as among high-risk patients with prior myocardial infarction 7,9,15,16 . Nevertheless, the optimal treatment duration of DAPT remains controversial as the protection afforded by extended DAPT in terms of ischaemic events is counterbalanced by an increase in bleeding complications 7,8 . Although the PEGASUS-TIMI 54 trial reported consistent results in terms of the primary ischaemic endpoint according to age, elderly patients represented less than 15% of the overall population 15 .…”

Section: Figure 3 Analysis Of Safety Outcomes Stratified By Age A) mentioning

confidence: 99%

“…Dual antiplatelet therapy (DAPT) with aspirin and oral P2Y 12 adenosine diphosphate receptor inhibitors represents the standard of treatment to prevent new atherothrombotic events after PCI, yet its optimal duration remains controversial [4][5][6] . Results from randomised trials and meta-analyses indicate that extended (i.e., >12 months) duration of DAPT is associated with a lower risk of ischaemic events, even though this benefit is partly offset by a higher risk of clinically relevant bleeding [7][8][9] .…”

Section: Introductionmentioning

confidence: 99%

Ischaemic and bleeding outcomes in elderly patients undergoing a prolonged versus shortened duration of dual antiplatelet therapy after percutaneous coronary intervention: insights from the PRODIGY randomised trial

Piccolo

Ariotti²,

Gargiulo³

et al. 2017

EuroIntervention

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Aims: The aim of this study was to evaluate the efficacy and safety of 24-month vs. six-month dual antiplatelet therapy (DAPT) among elderly (≥75 years) and non-elderly patients (<75 years) undergoing percutaneous coronary intervention. Methods and results:The primary efficacy endpoint of the PRODIGY trial was the composite of death, myocardial infarction, or cerebrovascular accident at 24-month follow-up. The key safety endpoint was type 2, 3 or 5 bleeding according to the BARC criteria. Of 1,970 participants, 587 (29.8%) were elderly and had a higher risk of adverse events compared with younger patients. The risk of the primary endpoint was not significantly reduced with 24-month compared to six-month DAPT among both elderly (HR 0.80, 95% CI: 0.55-1.16, p=0.24) and non-elderly patients (HR 1.48, 95% CI: 0.95-2.30, p=0.08), although interaction testing was significant (p=0.036). A 24-month versus six-month DAPT significantly increased the risk of BARC type 2, 3 or 5 bleeding in both older (HR 1.90, 95% CI: 1.06-3.38, p=0.03) and younger patients (HR 2.54, 95% CI: 1. 43-4.53, p=0.002, p-interaction=0.48). However, measures of absolute risk difference indicated a less favourable safety profile of prolonged DAPT for older rather than younger patients. Conclusions:In the PRODIGY trial, prolonging clopidogrel-based DAPT beyond six months in elderly patients increased the risk of bleeding, without affording a significant prevention of ischaemic events.

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“…Tullio Palmerini and his colleague performed a pairwise and Bayesian network meta-analysis to analyse the optimal duration of DAPT in many randomised trials. 16 They concluded that shorter DAPT lower all-cause mortality compared with longer DAPT and shorter DAPT reduced the risk of major bleeding but increased myocardial infarction and stent thrombosis; network meta-analysis shown that the risk of lower all-cause mortality and non-cardiac mortality observed in patients with DAPT for 6-month or shorter or for 1 year than patients treated over 1 year.…”

Section: The Efficacy Of Dual Antiplatelet Therapymentioning

confidence: 99%

The Development of Antiplatelet Therapy after Percutaneous Coronary Intervention

Duan

Gong

2017

IPMRJ

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Coronary artery disease is one of the common cardiovascular diseases and threatens our health. Percutaneous coronary intervention (PCI) is the main treatment for coronary artery disease. Bare-metal stents (BMS) and drug-eluting stents (DES) are popularly applied in clinical practice. With the development of clinic and technology, DES is widely used in coronary artery disease following antiplatelet therapy. Clinical guidelines require dual antiplatelet therapy (DAPT) after PCI in USA and Europe. It is effective to reduce the incident of stent thrombosis, myocardial infarction and major adverse cardiac. However, the risk of major adverse cardiac events and bleeding was increased by DAPT. Therefore, single antiplatelet therapy was induced in various clinical trials. We searched previous research from PubMed, Embase Web of Science

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Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials

Cited by 357 publications

References 29 publications

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Ischaemic and bleeding outcomes in elderly patients undergoing a prolonged versus shortened duration of dual antiplatelet therapy after percutaneous coronary intervention: insights from the PRODIGY randomised trial

The Development of Antiplatelet Therapy after Percutaneous Coronary Intervention

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