Advertisement
Canadian Journal of Cardiology

Optimal Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: An Umbrella Review

Published:February 06, 2019DOI:https://doi.org/10.1016/j.cjca.2019.01.021

      Abstract

      Background

      The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention with stenting requires consideration of patient characteristics, and decision makers require a comprehensive overview of the evidence.

      Methods

      We performed an umbrella review of systematic reviews (SRs) of randomized controlled trials of extended DAPT (> 12 months) compared with DAPT for 6 to 12 months after percutaneous coronary intervention with stenting. Outcomes of interest were death, myocardial infarction (MI), stroke, stent thrombosis, major adverse cardiac and cerebrovascular events, bleeding, and urgent revascularization. We aimed to assess the evidence of benefits and harms among clinically important subgroups (eg, elderly patients, those with diabetes, prior MI, acute coronary syndrome). We assessed the quality of the included reviews by use of A Measurement Tool to Assess Systematic Reviews (AMSTAR).

      Results

      Sixteen SRs involving 8 randomized controlled trials were included. Most scored 7 or more points on the AMSTAR checklist. There was no significant difference in outcomes with extended DAPT compared with 6 months of DAPT in most SRs, with the exception of an increased risk of major bleeding. Compared with 12 months, extended DAPT may reduce the risk of MI and stent thrombosis; however, the findings were not consistent across all reviews. There have been conflicting reports of an increased risk of death with extended DAPT. Few SRs assessed outcomes among patient subgroups.

      Conclusions

      Extended DAPT may reduce the risk of MI and stent thrombosis but increase the risk of major bleeding and death. Whether the effects of extended DAPT are consistent across patient subgroups is unclear, and future SRs should address this knowledge gap.

      Résumé

      Contexte

      Pour déterminer la durée optimale de la bithérapie antiplaquettaire après la pose d’une endoprothèse par intervention coronarienne percutanée, il faut tenir compte des caractéristiques du patient et avoir une bonne vue d’ensemble des données probantes.

      Méthodologie

      Nous avons examiné l’ensemble des revues systématiques des essais contrôlés avec répartition aléatoire comparant la bithérapie antiplaquettaire prolongée (> 12 mois) et la bithérapie antiplaquettaire d’une durée de 6 à 12 mois après la pose d’une endoprothèse par intervention coronarienne percutanée. Les paramètres d’intérêt étaient le décès, l’infarctus du myocarde (IM), l’accident vasculaire cérébral, la thrombose de l’endoprothèse, les événements vasculaires cérébraux et cardiaques majeurs, l’hémorragie et la nécessité d’une revascularisation d’urgence. Notre objectif était d’évaluer les données à l’appui des bienfaits et des effets nocifs observés dans différents sous-groupes d’importance clinique (p. ex., patients âgés, atteints de diabète, ayant déjà subi un IM ou présentant un syndrome coronarien aigu). Nous avons évalué la qualité des revues incluses dans notre examen à l’aide de l’outil AMSTAR (A Measurement Tool to Assess Systematic Reviews).

      Résultats

      Seize revues systématiques portant sur 8 essais contrôlés avec répartition aléatoire ont été incluses dans l’examen. La plupart ont obtenu 7 points ou plus au questionnaire de contrôle de la qualité de l’outil AMSTAR. Aucune différence significative n’a été relevée entre les résultats obtenus sous bithérapie antiplaquettaire prolongée et sous bithérapie antiplaquettaire d’une durée de 6 mois dans la plupart des revues systématiques, sauf en ce qui concerne le risque accru d’hémorragie majeure. Comparativement à un traitement sur une période de 12 mois, la bithérapie antiplaquettaire prolongée peut réduire le risque d’IM et de thrombose de l’endoprothèse; cependant, les constatations des différentes revues ne concordaient pas toujours. Les données rapportées en ce qui concerne le risque accru de décès chez les patients recevant une bithérapie antiplaquettaire prolongée sont contradictoires. Peu de revues systématiques ont évalué les résultats dans différents sous-groupes de patients.

      Conclusions

      Une bithérapie antiplaquettaire prolongée peut réduire le risque d’IM et de thrombose de l’endoprothèse, mais aussi accroître le risque d’hémorragie majeure et de décès. Nous n’avons pas pu déterminer avec certitude si les effets d’une bithérapie antiplaquettaire prolongée sont les mêmes dans tous les sous-groupes de patients; d’autres revues systématiques s’imposent afin de combler cette lacune dans les connaissances.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Levine G.N.
        • Bates E.R.
        • Mauri L.
        • et al.
        2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery.
        Circulation. 2016; 134: e123-e155
        • Mehta S.R.
        • Bainey K.R.
        • Cantor W.J.
        • et al.
        2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology focused update of the guidelines for the use of antiplatelet therapy.
        Can J Cardiol. 2018; 34: 214-233
        • Jeppsson A.
        • Petricevic M.
        • Kolh P.
        • Valgimigli M.
        2017 European Society of Cardiology (ESC) focused update on dual antiplatelet therapy in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).
        Eur J Cardiothorac Surg. 2018; 53: 3-4
        • Fei Y.
        • Tsoi M.F.
        • Cheung T.T.
        • Cheung B.M.
        Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: meta-analysis of randomized controlled trials.
        Int J Cardiol. 2016; 220: 895-900
        • Palla M.
        • Briasoulis A.
        • Siddiqui F.
        • Alesh I.
        • Afonso L.
        Long (>12 months) and short (<6 months) versus standard duration of dual antiplatelet therapy after coronary stenting: a systematic review and meta-analysis.
        Am J Ther. 2015; : e468-e476
        • D'Ascenzo F.
        • Moretti C.
        • Bianco M.
        • et al.
        Meta-analysis of the duration of dual antiplatelet therapy in patients treated with second-generation drug-eluting stents.
        Am J Cardiol. 2016; 117: 1714-1723
        • Tsoi M.F.
        • Cheung C.L.
        • Cheung T.T.
        • et al.
        Duration of dual antiplatelet therapy after drug-eluting stent implantation: meta-analysis of large randomised controlled trials.
        Sci Rep. 2015; 5: 13204
        • Verdoia M.
        • Schaffer A.
        • Barbieri L.
        • et al.
        Optimal duration of dual antiplatelet therapy after DES implantation: a meta-analysis of 11 randomized trials.
        Angiology. 2015; 67: 224-238
        • Cassese S.
        • Byrne R.A.
        • Ndrepepa G.
        • et al.
        Prolonged dual antiplatelet therapy after drug-eluting stenting: meta-analysis of randomized trials.
        Clin Res Cardiol. 2015; 104: 887-901
        • Palmerini T.
        • Benedetto U.
        • Bacchi-Reggiani L.
        • et al.
        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.
        Lancet. 2015; 385: 2371-2382
        • Navarese E.P.
        • Andreotti F.
        • Schulze V.
        • et al.
        Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug eluting stents: meta-analysis of randomised controlled trials.
        BMJ. 2015; 350: h1618
        • Xie C.
        • Ding X.L.
        • Miao L.Y.
        Different durations of dual anti-platelet therapy after percutaneous coronary intervention with drug-eluting stents in patients with coronary disease: a systematic review.
        Chinese Pharma J. 2016; 51: 762-768
        • Zhang X.L.
        • Zhu Q.Q.
        • Zhu L.
        • et al.
        Optimize the duration of DAPT following DES implantation: an updated system review and meta-analysis of 10 randomized trials.
        Clin Trials Regul Sci Cardiol. 2015; 6: 1-11
        • Bittl J.
        • Baber U.
        • Bradley S.
        • Wijeysundera D.
        Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines.
        Circulation. 2016; 68: 1116
        • Aromataris E.
        • Fernandez R.
        • Godfrey C.
        • Holly C.
        • Khalil H.
        • Tungpunkom P.
        Chapter 10: Umbrella reviews.
        in: Aromataris E. Munn Z. Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017 (Available at:) (Accessed June 13, 2019)
        • Elliott J.
        • Kelly S.E.
        • Bai Z.
        • et al.
        Optimal duration of dual antiplatelet therapy following percutaneous coronary intervention: protocol for an umbrella review.
        BMJ Open. 2017; 7: e015421
        • Shea B.J.
        • Grimshaw J.M.
        • Wells G.A.
        • et al.
        Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews.
        BMC Med Res Methodol. 2007; 7: 10
        • Mauri L.
        • Kereiakes D.J.
        • Yeh R.W.
        • et al.
        Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents.
        New Engl J Med. 2014; 371: 2155-2166
        • Valgimigli M.
        • Campo G.
        • Monti M.
        • et al.
        Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: a randomized multicenter trial.
        Circulation. 2012; 125: 2015-2026
        • Huang H.
        • Li Y.
        • Chen Y.
        • Fu G.S.
        Shorter- versus longer-duration dual antiplatelet therapy in patients with diabetes mellitus undergoing drug-eluting stents implantation: a meta-analysis of randomized controlled trials.
        Chin Med J. 2016; 129: 2861
        • Bavishi C.
        • Trivedi V.
        • Singh M.
        • et al.
        Duration of dual antiplatelet therapy in patients with an acute coronary syndrome undergoing percutaneous coronary intervention.
        Am J Med. 2017; 130: 1325
        • Gilard M.
        • Barragan P.
        • Noryani A.A.L.
        • et al.
        6- versus 24-month dual antiplatelet therapy after implantation of drug-eluting stents in patients nonresistant to aspirin: the randomized, multicenter ITALIC trial.
        J Am Coll Cardiol. 2015; 65: 777-786
        • Collet J.P.
        • Silvain J.
        • Barthélémy O.
        • et al.
        Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): a randomised trial.
        Lancet. 2014; 384: 1577-1585
        • Lee C.W.
        • Ahn J.M.
        • Park D.W.
        • et al.
        Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation a randomized, controlled trial.
        Circulation. 2014; 129: 304-312
        • Park S.-J.
        • Park D.-W.
        • Kim Y.-H.
        • et al.
        Duration of dual antiplatelet therapy after implantation of drug-eluting stents.
        New Engl J Med. 2010; 362: 1374-1382
        • Hu T.
        • Wang H.C.
        AS-171 duration of dual antiplatelet therapy and outcomes after left main percutaneous coronary intervention.
        Am J Cardiol. 2012; 197: S85-S86
        • Tang W.
        • Yeh J.
        • Chen J.
        • et al.
        Meta-analysis of randomized controlled trials on efficacy and safety of extended thienopyridine therapy after drug-eluting stent implantation.
        Cardiovasc Diagn Ther. 2016; 6: 409
        • Ferrante G.
        • Condorelli G.
        • Pagnotta P.
        • Reimers B.
        Dual antiplatelet therapy continuation beyond 1 year after drug-eluting stents: a meta-analysis of randomized trials.
        Circ Cardiovasc Interv. 2017; 10: e004139
        • Wang W.
        • Liu J.
        • Fang J.
        • et al.
        The optimal discontinuation of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention with drug-eluting stents: a meta-analysis of randomized trials.
        Int J Cardiol. 2017; 235: 73