Short Versus Long-Term Dual Antiplatelet Therapy in Patients at High Bleeding Risk Undergoing PCI in Contemporary Practice: A Systemic Review and Meta-analysis

Nader Mankerious; Michael Megaly; Rayyan Hemetsberger; Abdelhakim Allali; Mohamed Samy; Ralph Toelg; Santiago Garcia; Gert Richardt

doi:10.1007/s40119-023-00318-5

Short Versus Long-Term Dual Antiplatelet Therapy in Patients at High Bleeding Risk Undergoing PCI in Contemporary Practice: A Systemic Review and Meta-analysis

Cardiol Ther. 2023 Sep;12(3):489-498. doi: 10.1007/s40119-023-00318-5. Epub 2023 Jun 1.

Authors

Nader Mankerious^{1

2}, Michael Megaly^{3

4}, Rayyan Hemetsberger⁵, Abdelhakim Allali⁶, Mohamed Samy⁷, Ralph Toelg⁶, Santiago Garcia³, Gert Richardt⁶

Affiliations

¹ Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany. nader.mankerious@gmail.com.
² Cardiology Department, Zagazig University, Sharkia, Egypt. nader.mankerious@gmail.com.
³ Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA.
⁴ Division of Cardiology, Hennepin Healthcare, Minneapolis, MN, USA.
⁵ Department of Cardiology and Angiology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany.
⁶ Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany.
⁷ Cardiology Department, Zagazig University, Sharkia, Egypt.

Abstract

Introduction: Patients at high bleeding risk (HBR patients) represent an important subset of patients undergoing percutaneous coronary intervention (PCI). It remains unclear whether a shortened duration of dual antiplatelet therapy (DAPT) confers benefits compared with prolonged duration of DAPT in this patient population. The aim of this study was to investigate and compare bleeding and ischemic outcomes among HBR patients receiving short- versus long-term DAPT after PCI.

Methods: A meta-analysis of studies comparing short-term (1-3 months) and long-term (6-12 months) DAPT after PCI with second-generation drug-eluting stents in HBR patients was performed.

Results: Six studies [1 randomized controlled trial (RCT), 2 RCT subanalyses, and 3 prospective propensity-matched studies] involving 15,908 patients were included in the meta-analysis. During a follow-up of 12 months, short-term DAPT was associated with a reduction in major bleeding events [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.42-0.95; p = 0.03, I² = 71] and comparable definite/probable stent thrombosis, all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and ischemic stroke, compared with long-DAPT. Single antiplatelet therapy (SAPT) with aspirin was comparable to SAPT with P2Y12 inhibitor, with no treatment-by-subgroup interaction for major bleeding events (p-interaction = 0.27). In studies including patients presenting with MI, a trend of more frequent MI was noted in the short-DAPT arm (OR 1.25, 95% CI 0.98-1.59; p = 0.07; I² = 0). In a sensitivity analysis comparing 3- and 12-month DAPT, the 3-month DAPT strategy was associated with a higher risk of ischemic stroke (OR 2.37, 95% CI 1.15-4.87; p = 0.02, I² = 0%).

Conclusion: Short-term DAPT after PCI in HBR patients was associated a reduction in major bleeding events and similar ischemic outcomes. However, a higher risk of ischemic stroke and MI at 1 year of follow-up was seen in some subsets.

Keywords: Dual antiplatelet therapy; High bleeding risk; Percutaneous coronary intervention.