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Longer Versus Shorter Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement: A Systematic Review and Meta-analysis.
Ann Intern Med. 2015 May 26;
Authors: Spencer FA, Vandvik PO, Chetan D, Zhou Q, Guyatt G
Abstract
Background: The appropriate duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) placement remains controversial.
Purpose: To summarize data on clinical outcomes with longer- versus shorter-duration DAPT after DES placement in adults with coronary artery disease.
Data Sources: Ovid MEDLINE and EMBASE, 1996 to 27 March 2015, and manual screening of references.
Study Selection: Randomized, controlled trials comparing longer- versus shorter-duration DAPT after DES placement.
Data Extraction: Two reviewers screened potentially eligible articles; extracted data on populations, interventions, and outcomes; assessed risk of bias; and used the Grading of Recommendations Assessment, Development and Evaluation guidelines to rate overall confidence in effect estimates.
Data Synthesis: Among 1010 articles identified, 9 trials including 29 531 patients were eligible; data were complete for 28 808 patients. Moderate-quality evidence showed that longer-duration DAPT decreased risk for myocardial infarction (risk ratio [RR], 0.73 [95% CI, 0.58 to 0.92]) and increased mortality (RR, 1.19 [CI, 1.04 to 1.36]). High-quality evidence showed that DAPT increased risk for major bleeding (RR, 1.63 [CI, 1.34 to 1.99]).
Limitations: Confidence in estimates were decreased owing to imprecision for most outcomes (particularly myocardial infarction), risk of bias from limited blinding in 7 of 9 studies, indirectness due to variability in use of first- and second-generation stents, and off-protocol use of DAPT in some studies.
Conclusion: Extended DAPT is associated with approximately 8 fewer myocardial infarctions per 1000 treated patients per year but 6 more major bleeding events than shorter-duration DAPT. Because absolute effects are very small and closely balanced, decisions regarding the duration of DAPT therapy must take into account patients' values and preference judgments.
Primary Funding Source: None.
PMID: 26005909 [PubMed - as supplied by publisher]