De-escalation of antiplatelet therapy after percutaneous coronary intervention among East Asians and non-East Asians: a meta-analysis of randomized controlled trials

Background: To study the impact of de-escalation antiplatelet therapy retaining P2Y12 inhibition on major bleeding and ischemic outcomes after percutaneous coronary intervention (PCI) among East Asians and non-East Asians was unclear.

Methods: We systematically searched PubMed, Embase, and the Cochrane Library for randomized controlled trials through September 2020. Eight trials were included, which studied de-escalation of DAPT (D-DAPT, switching to P2Y12 inhibitor monotherapy, or switching to clopidogrel or dose reduction of the P2Y12 inhibitor after 1 to 3 months) versus 12 months standard DAPT (S-DAPT). The primary outcomes data was conducted using random effects models.

Results: Among the 8 included trials consisting of 37,775 patients, 62.6% presented with acute coronary syndrome. The median follow-up duration ranged from 12 to 24 months. Compared with S-DAPT, D-DAPT was associated with a lower risk of major bleeding (RR = 0.67, 95% CI 0.48-0.93, p = 0.02); however, this was only observed among East-Asians (RR = 0.61, 95% CI 0.37-0.99, p = 0.048). Among non-East Asians, the rate of major bleeding was similar between the two groups (RR = 0.73, 95% CI 0.46-1.14, p = 0.17, p for interaction = 0.59). There were no significant differences in the major adverse cardiovascular events (MACE) between D-DAPT and S-DAPT treatment among both East Asians (RR = 0.84, 95% CI 0.66-1.08, p = 0.18) and non-East Asians (RR = 0.89, 95% CI 0.79-1.00, p = 0.059, p for interaction = 0.71).

Conclusions: The De-escalation strategy that retains P2Y12 inhibition after a PCI was associated with reduced risk of bleeding events, which was only demonstrated in East Asians patients, and not in non-East Asian patients.