Circulation. 2020 Aug 3. doi: 10.1161/CIRCULATIONAHA.120.046308. Online ahead of print.
Background: The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) remains uncertain. We compared short-term (<6-month) DAPT followed by aspirin or P2Y12 inhibitor monotherapy; mid-term (6-month) DAPT; 12-month DAPT; and extended-term (>12-month) DAPT after PCI with DES. Methods: Twenty-four randomized controlled trials were selected using Medline, Embase, Cochrane library, and online databases through September 2019. The co-primary endpoints were myocardial infarction (MI) and major bleeding, which constituted the net clinical benefit. A frequentist network meta-analysis was conducted with random effects model. Results: In 79,073 patients, at a median follow-up of 18 months, extended-term DAPT was associated with a reduced risk of MI compared with 12-month DAPT (absolute risk difference [ARD], -3.8 incident cases per 1000 person-years; relative risk (RR), 0.68 [95% CI, 0.54-0.87]), mid-term DAPT (ARD, -4.6 incident cases per 1000 person-years; RR, 0.61 [0.45-0.83]), and short-term DAPT followed by aspirin monotherapy (ARD, -6.1 incident cases per 1000 personyears; RR, 0.55 [0.37-0.83]), or P2Y12 inhibitor monotherapy (ARD, -3.7 incident cases per 1000 person-years; RR, 0.69 [0.51-0.95]). Conversely, extended-term DAPT was associated with a higher risk of major bleeding compared with all other DAPT groups. Compared with 12-month DAPT, no significant differences in the risks of ischemic endpoints or major bleeding were observed with mid-term or short-term DAPT followed by aspirin monotherapy, except that shortterm DAPT followed by P2Y12 inhibitor monotherapy was associated with a reduced risk of major bleeding. There were no significant differences with respect to mortality between the different DAPT strategies. In acute coronary syndrome (ACS), extended-term compared with 12-month DAPT was associated with a reduced risk of MI without significant increase in the risk of major bleeding. Conclusions: The present network meta-analysis suggests that compared with 12-month DAPT, short-term DAPT followed by P2Y12 inhibitor monotherapy reduces major bleeding after PCI with DES, while extended-term DAPT reduces myocardial infarction at the expense of more bleeding events.