Benefits and risks of long-term duration of dual antiplatelet therapy after drug-eluting stenting: a meta-analysis of randomized trials

Background: The potential benefits and risks of at least 1-year dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) implantation remain uncertain.

Methods and results: PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched from database inception to December 2011 for randomized controlled trials that compared longer DAPT versus shorter DAPT duration after DES. Unpublished data were obtained from investigators. Trial-specific odds ratios (ORs) with 95% confidence interval (CI) were calculated and pooled using fixed-effects or random-effects model as appropriate. Data were independently extracted by 2 reviewers. Three randomized controlled trials comprising 5622 participants were included. Compared with patients receiving short-term therapy, participants receiving longer DAPT duration had a pooled OR of 1.26 (95% CI, 0.88 to 1.80; P=0.21, random-effects) for the primary outcome of cardiac death, myocardial infarction or stroke, OR of 1.29 (95% CI, 0.85 to 1.93; fixed-effects) for all-cause death, 1.23 (95% CI, 0.78 to 1.93; fixed-effects) for cardiac death, 0.91 (95% CI, 0.58 to 1.42; random-effects) for myocardial infarction, 1.93 (95% CI, 1.01 to 3.69; fixed-effects) for stroke and 2.51 (95% CI, 1.10 to 5.71, fixed-effects) for TIMI major bleeding. The number needed to treat for an additional harmful outcome was 217.6 for stroke and 243 for TIMI major bleeding.

Conclusions: This meta-analysis provides no evidence of benefits with longer DAPT duration as compared with a shorter course of therapy. It also reports significant harms with respect to major bleeding and stroke associated with prolonged DAPT use.