Different Duration Of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Drug-eluting Stents In Coronary Disease: A Systematic Review

Objective: To evaluate the benefits and risks among different duration of dual antiplatelet therapy(DAPT) after percutaneous coronary intervention(PCI) with drug-eluting stent(DES) in coronary disease.Methods: We searched PUBMED, EMBASE, Cochrane Library, CBM, CNKI, VIP, Wanfang Data, Clinical Trials, ICTRP and proceedings of international meetings for RCT comparing different DAPT durations after PCI with DES in coronary disease. Two reviewers included and excluded studies independently according to the eligibility criteria, and extracted data independently with a pre-designed data extract form. Risk of bias was assessed with the tool recommended by Cochrane Collaboration. Pair-wise comparison between shoter and longer durations was performed with Rev Man, and network meta-analysis was performed with Win BUGS and STATA.Results: We searched 3230 articles and systematically reviewed 10 randomized controlled trials(RCT) including 31643 patients. There were 6 groups of 3 vs 12 months, 6 vs 12 months, 6 vs 24 months, 12 vs 24 months, 12 vs 30 months and 12 vs 36 months of DAPT. Pair-wise comparison showed shorter DAPT was associated with significantly higher rates of stent thrombosis(RR 1.73, 95% CI 1.10–2.74) and myocardial infarction(RR 1.33, 95% CI 1.04–1.71) but lower rates of all-cause death(RR 0.83, 95% CI 0.70–0.99), major bleeding(RR 0.61, 95% CI 0.49–0.76) and bleeding(RR 0.61, 95% CI 0.47–0.80) compared with longer DAPT. Subgroup analysis showed shorter DAPT was associated with significantly lower rates of stent thrombosis and myocardial infarction for patients with PES(RR 3.38, 95%CI 1.86-6.12 and RR 2.37, 95%CI 1.31-4.27, separately), SES(RR 8.21, 95%CI 1.03-65.55 and RR 2.40, 95%CI 1.15-5.03, separately) and EES(RR 2.66, 95%CI 1.20-5.90 and RR 1.52, 95%CI 1.11-2.09, separately). Network meta-analysis showed there was no significantly difference among the 6 different durations in the rates of stent thrombosis, myocardial infarction, all-cause death and major bleeding. Ranking of cumulative probabilities showed 30 months and 36 months of DAPT have the lowest risk of stent thrombosis and myocardial infarction but the highest risk of all-cause death and major bleeding, meanwhile 6 months has the lowest risk of stent thrombosis and myocardial infarction, and 3 months and 6 months have the lowest risk of all-cause death and major bleeding.Conclusions: The risks of stent thrombosis and myocardial infarction were decreased with the extension of DAPT, but the risks of all-cause death and major bleeding were increased in patients with DES after PCI. Clinician should assess the risks of stent thrombosis and bleeding according to patient’s individual condition and make the optimal duration of DAPT. It is considered feasible to appropriately extend the duration of DAPT in patients at lower bleeding risk, particularly for patients with PES, SES and EES.