Longer-Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement A Systematic Review and Meta-analysis

Background: The appropriate duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) placement remains controversial. Purpose: To summarize data on clinical outcomes with longer-versus shorter-duration DAPT after DES placement in adults with coronary artery disease. Data Sources: Ovid MEDLINE and EMBASE, 1996 to 27 March 2015, and manual screening of references. Study Selection: Randomized, controlled trials comparing longer-versus shorter-duration DAPT after DES placement. Data Extraction: Two reviewers screened potentially eligible articles; extracted data on populations, interventions, and outcomes; assessed risk of bias; and used the Grading of Recommendations Assessment, Development and Evaluation guidelines to rate overall confidence in effect estimates. Data Synthesis: Among 1010 articles identified, 9 trials including 29 531 patients were eligible; data were complete for 28 808 patients. Moderate-quality evidence showed that longer-duration DAPT decreased risk for myocardial infarction (risk ratio [RR], 0.73 [95% CI, 0.58 to 0.92]) and increased mortality (RR, 1.19 [CI, 1.04 to 1.36]). High-quality evidence showed that DAPT increased risk for major bleeding (RR, 1.63 [CI, 1.34 to 1.99]). Limitation: Confidence in estimates were decreased owing to imprecision for most outcomes (particularly myocardial infarction), risk of bias from limited blinding in 7 of 9 studies, indirectness due to variability in use of first-and second-generation stents, and off-protocol use of DAPT in some studies. Conclusion: Extended DAPT is associated with approximately 8 fewer myocardial infarctions per 1000 treated patients per year but 6 more major bleeding events than shorter-duration DAPT. Because absolute effects are very small and closely balanced, decisions regarding the duration of DAPT therapy must take into account patients' values and preference.