Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials

Navarese, Eliano Pio; Andreotti, Felicita; Schulze, Volker; Kołodziejczak, Michalina; Buffon, Antonino; Brouwer, Marc A.; Costa, Francesco; Kowalewski, Mariusz; Parati, Gianfranco; Lip, Gregory Y.H.; Kelm, Malte; Valgimigli, Marco

doi:10.1136/bmj.h1618

Cited by 295 publications

(232 citation statements)

References 39 publications

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“…Previous meta-analyses of RCTs comparing S-DAPT versus L-DAPT have shown inconsistent results [14][15][16][17]. Furthermore, results of most recent RCT comparing L-DAPT and S-DAPT-Optimal Duration of Dual Antiplatelet Therapy After Drug-eluting Stent Implantation (OPTIDUAL)-showed non superiority of L-DAPT (48 months) over standard (12 months) DAPT, after extended median follow up of 33 months [13].…”

mentioning

confidence: 99%

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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confidence: 99%

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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“…Common to most meta-analyses is the lack of individual patient data which precludes detailed exploration of adjunctive therapies and other covariates which might have had an impact on bleeding and thrombotic outcomes, such as type, dose and duration of P2Y12 inhibitor administration (25), and radial or femoral vascular access site. The probability statements should be interpreted with caution.…”

Section: Study Limitationsmentioning

confidence: 99%

Comparative efficacy and safety of anticoagulant strategies for acute coronary syndromes

Navarese

Andreotti²,

Kołodziejczak³

et al. 2015

Thromb Haemost

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SummaryInternational guidelines differ in strengths of recommendation for anticoagulation strategies in acute coronary syndromes (ACS). We performed a comprehensive network meta-analysis (NMA) of randomised controlled trials (RCTs) to investigate the comparative efficacy and safety of parenteral anticoagulants in ACS. MEDLINE, Cochrane, EM-BASE, Google Scholar, major cardiology websites, and abstracts/presentations were searched. Six treatments were identified: 1) unfractionated heparin (UFH) + glycoprotein IIb/IIIa inhibitor (GPI)[UFH+GPI], 2) UFH±GPI, 3) bivalirudin, 4) low-molecular-weight heparins (LMWHs), 5) otamixaban, and 6) fondaparinux. Prespecified outcomes (death, myocardial infarction [MI], revascularisation, major bleeding [MB], minor bleeding, and stent thrombosis [ST]) were evaluated up to 30 days. Forty-two RCTs involving 117,353 patients were included. No significant differences in mortality rates were found among strategies. Compared to UFH+GPI, bivalirudin reduced the odds of MB but increased the odds of ST and MI. LMWHs vs bivalirudin reduced MI risk at the price of MB excess. UFH±GPI significantly increased the odds of MI vs LMWHs, of ST vs UFH+GPI, and of MB vs bivalirudin. Reduced ST risk with otamixaban vs UFH±GPI and vs bivalirudin was offset by a marked 2.5-to four-fold MB excess. Fondaparinux showed an intermediate profile. Results for ST-segment elevation MI were consistent with the overall findings. Early anticoagulant strategies for ACS differ in efficacy and safety, with UFH+GPI and LMWHs reducing ischaemic but increasing bleeding risk, and bivalirudin reducing MB but increases MI and ST. The findings support individualised therapy based on patients' bleeding and ischaemic risks.

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“…A shorter DAPT duration yields fewer bleeding events than a longer DAPT duration with comparable efficacy against ischemic complications. However, alonger DAPT duration yields a marked reduction of thrombotic complications at the price of increased bleeding rates [55]. The current recommendation is for 12 months duration of DAPT after drug eluting stent implementation as a compromise between ischaemic and bleeding risks [55].…”

Section: Dual Antiplatelet Therapy (Dapt)mentioning

confidence: 99%

“…In essence, CABG and PCI patients have the same underlying coronary pathomorphology, despite the fact that they are managed with deferent interventions. A recent meta-analysis of 10 RCTs (n=32 287) compared risks of short term (<12 months) or extended (>12 months) DAPT versus the standard of 12 months therapy, following PCI with drug eluting stents [55]. Short term DAPT use was associated with a significant reduction in major bleeding when compared with prolonged DAPT use (odds ratio 0.58 95% confidence interval 0.36 to 0.92).…”

mentioning

confidence: 99%

“…However, alonger DAPT duration yields a marked reduction of thrombotic complications at the price of increased bleeding rates [55]. The current recommendation is for 12 months duration of DAPT after drug eluting stent implementation as a compromise between ischaemic and bleeding risks [55]. However, although we can extrapolate from the PCI population with regards to the impact of DAPT on bleeding, we can't extrapolate with regards to the impact on ischaemic outcomes, since studies have shown that stent thrombosis has a greater effect on short-term and long-term mortality than graft occlusion [56].…”

mentioning

confidence: 99%

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http://oatext.com/Dual-antiplatelet-therapy-after-coronary-artery-bypass-grafting-Do-we-have-a-consensus.php

Jaaly¹,

Zakkar²,

Pufulete³

et al. 2015

J Integr Cardiol

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Coronary artery bypass grafting (CABG) remains the gold standard treatment in patients with complex multivessel coronary artery disease (CAD). Reversed long saphenous vein is the most commonly used conduit despite the known early thrombotic failure and low long-term patency rate. Post-operative antiplatelet therapy is an established treatment to improve graft patency and also a secondary treatment of the underlying native CAD.Aspirin has traditionally been the first line therapy; however, aspirin resistance especially in the early period after CABG, has been reported over the years and as a result, the use of dual antiplatelet therapy (DAPT) has become more common. However, there is limited evidence about the effect of DAPT and duration of use after CABG on graft patency, clinical outcomes (such as bleeding and myocardial infarction), and survival. The optimal dose of aspirin when given in DAPT is unclear and the duration of DAPT in association with quality of life is unknown.Furthermore, a better understanding of the pathology of vein graft disease and how available drugs influence it, could lead to the development of customised therapy for cohorts of patients undergoing CABG with potential benefits to early and long term outcomes. Here we review the available evidence on the routine use of DAPT after CABG. Coronary artery bypass grafting (CABG)Ischaemic heart disease (IHD) is the main leading cause of death in the world, with 7.4 million deaths in 2012 [1,2]. Coronary artery bypass grafting (CABG) is the gold standard intervention in patients with complex multivessel disease [3]. In the UK, there are about 25,000 CABG operations performed annually [4] and the majority of these operations is carried out on patients over 70 years of age [5]. Demand for CABG is likely to increase considerably in the future as a result of rapidly ageing populations [6] and increased expectations of patients and surgeons to expand their indications for surgery.During the early years of coronary surgery, saphenous vein grafts (SVGs) were the only conduits used [7]. Over the years different arterial conduits were introduced with variable degree of success [8][9][10]. Contemporary data on international use of grafts are available from the SYNTAX trial that included 1541 patients who underwent CABG at 85 sites in 18 countries between 2005 and 2007 [11]. The SYNTAX trial confirmed that the long saphenous vein (LSV) graft, is the most used conduit for multivessel revascularisation, despite its known low early and late patency rates.The underlying mechanism behind vein graft disease is multifactorial and can include conduit trauma/graft thrombosis (within 1 month, early failure), activation of intimal hyperplasia associated with harvest and implantation into the arterial high-pressure system (1 to 12 months, intermediate failure), superimposed atherosclerosis (beyond 12 months, late failure) [12][13][14][15]. A prospective cohort study of 1,388 patients carried out between 1969 to 1994, in which patency was assessed using coronary...

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Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials

Cited by 295 publications

References 39 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

Comparative efficacy and safety of anticoagulant strategies for acute coronary syndromes

http://oatext.com/Dual-antiplatelet-therapy-after-coronary-artery-bypass-grafting-Do-we-have-a-consensus.php

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