Dual antiplatelet therapy duration after percutaneous coronary intervention in patients with indication to oral anticoagulant therapy. A systematic review and meta-analysis of randomized controlled trials

Author:

Montalto Claudio12ORCID,Costa Francesco3ORCID,Leonardi Sergio1ORCID,Micari Antonio34,Oreglia Jacopo A2,Vranckx Pascal5,Capodanno Davide6ORCID,ten Berg Jurriën7,Lopes Renato D8ORCID,Valgimigli Marco9ORCID

Affiliation:

1. Department of Molecular Medicine, University of Pavia , 27100 Pavia , Italy

2. De Gasperis Cardio Center, Interventional Cardiology Unit , Niguarda Hospital, 20162 Milan , Italy

3. Interventional Cardiology Unit, A.O.U. Policlinic “G.Martino”, University of Messina , 98124 Messina , Italy

4. Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, A.O.U. Policlinic “G. Martino― Messina University of Messina , 98122 Messina , Italy

5. Department of Cardiology, Jessa Hospital, Stadsomvaart 11, 3500 Hasselt, Belgium; Faculty of Medicine and Life Sciences, University of Hasselt , 3500 Hasselt , Belgium

6. Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania , 95123 Catania , Italy

7. Department of Cardiology, St Antonius Hospital, 3435 Nieuwegein, Netherlands and MUMC , 6229 Maastricht , The Nehterlands

8. Duke Clinical Research Institute, Duke University Medical Center , 27708 Durham, NC , USA

9. Cardiocentro Ticino Institute, Division of Cardiology, and Università della Svizzera italiana (USI) , 6900 Lugano , Switzerland

Abstract

Abstract Aims Optimal duration of dual antiplatelet therapy (DAPT) in patients with concomitant indication to oral anticoagulation (OAC) is still debated. Methods and results A systematic review was performed on electronic databases to search for randomized controlled trials comparing an abbreviated or prolonged (≥3 months) DAPT regimen in patients with OAC and they were analysed in the framework of standard and network meta-analyses. Co-primary endpoints were major or clinically relevant non-major bleedings (MCRB) and major bleeding, while the composite of major adverse cardiovascular events (MACE) was the key safety endpoint. Five studies and 7 665 patients (abbreviated DAPT n = 3 843; prolonged DAPT n = 3 822) were included. Both MCRB and major bleeding were lower with abbreviated DAPT [risk ratio (RR) 0.69 (0.52–0.91); P = 0.01 and 0.70 (0.52–0.95); P = 0.01, respectively] while MACE [RR: 0.96 (0.70–1.33); P = 0.6], all-cause death, cardiovascular death, stent thrombosis, or myocardial infarction did not differ. Network meta-analysis showed that peri-procedural DAPT had the highest probability to prevent MCRB and major bleeding (97.1 and 92.0% respectively) when compared with both short (4–6 weeks) and longer (≥3 months) DAPT regimens. Sensitivity analyses and meta-regressions showed consistency in different clinical scenarios and suggested a larger bleeding reduction with P2Y12 inhibitors vs. aspirin after DAPT discontinuation. Conclusion In patients undergoing PCI with concomitant OAC indication, an abbreviated DAPT regimen reduced MCRB and major bleeding without increasing MACE or other ischaemic events. Peri-procedural DAPT and P2Y12 inhibitor monotherapy after DAPT withdrawal appear to be the best strategies to optimize the bleeding and ischaemic risk tradeoff. Trial registration. PROSPERO CRD284001

Publisher

Oxford University Press (OUP)

Subject

Pharmacology (medical),Cardiology and Cardiovascular Medicine

Reference43 articles.

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4. Mortality after bleeding versus myocardial infarction in coronary artery disease: a systematic review and meta-analysis;Piccolo;EuroIntervention J Eur Collab with Work Gr Interv Cardiol Eur Soc Cardiol,2021

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