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Lancet. 2015 Jun 13;385(9985):2371-82. doi: 10.1016/S0140-6736(15)60263-X. Epub 2015 Mar 14.

Mortality in patients treated with extended duration dual antiplatelet therapy after drug-eluting stent implantation: a pairwise and Bayesian network meta-analysis of randomised trials.

Author information

1
Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Italy.
2
Oxford Heart Center, Oxford University, Oxford, UK.
3
Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.
4
Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil.
5
Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, Korea.
6
Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
7
Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.
8
Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA.
9
Policlinico S Matteo, Pavia, Italy.
10
Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA. Electronic address: gs2184@columbia.edu.

Abstract

BACKGROUND:

Despite recent studies, the optimum duration of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent placement remains uncertain. We performed a meta-analysis with several analytical approaches to investigate mortality and other clinical outcomes with different DAPT strategies.

METHODS:

We searched Medline, Embase, Cochrane databases, and proceedings of international meetings on Nov 20, 2014, for randomised controlled trials comparing different DAPT durations after drug-eluting stent implantation. We extracted study design, inclusion and exclusion criteria, sample characteristics, and clinical outcomes. DAPT duration was categorised in each study as shorter versus longer, and as 6 months or shorter versus 1 year versus longer than 1 year. Analyses were done by both frequentist and Bayesian approaches.

FINDINGS:

We identified ten trials published between Dec 16, 2011, and Nov 16, 2014, including 31,666 randomly assigned patients. By frequentist pairwise meta-analysis, shorter DAPT was associated with significantly lower all-cause mortality compared with longer DAPT (HR 0·82, 95% CI 0·69-0·98; p=0·02; number needed to treat [NNT]=325), with no significant heterogeneity apparent across trials. The reduced mortality with shorter compared with longer DAPT was attributable to lower non-cardiac mortality (0·67, 0·51-0·89; p=0·006; NNT=347), with similar cardiac mortality (0·93, 0·73-1·17; p=0.52). Shorter DAPT was also associated with a lower risk of major bleeding, but a higher risk of myocardial infarction and stent thrombosis. We noted similar results in a Bayesian framework with non-informative priors. By network meta-analysis, patients treated with 6-month or shorter DAPT and 1-year DAPT had higher risk of myocardial infarction and stent thrombosis but lower risk of mortality compared with patients treated with DAPT for longer than 1 year. Patients treated with DAPT for 6 months or shorter had similar rates of mortality, myocardial infarction, and stent thrombosis, but lower rates of major bleeding than did patients treated with 1-year DAPT.

INTERPRETATION:

Although treatment with DAPT beyond 1 year after drug-eluting stent implantation reduces myocardial infarction and stent thrombosis, it is associated with increased mortality because of an increased risk of non-cardiovascular mortality not offset by a reduction in cardiac mortality.

FUNDING:

None.

PMID:
25777667
DOI:
10.1016/S0140-6736(15)60263-X
[Indexed for MEDLINE]

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