Feature | March 19, 2015

Dual Antiplatelet Therapy Associated with Increased Mortality after Drug-Eluting Stent Implantation

Meta-analysis finds longer DAPT associated with 22 percent increase in all-cause mortality

dual antiplatelet therapy, DAPT, mortality, DES implantation, CRF, length

March 19, 2015 — Data from a meta-analysis published recently in The Lancet found that extended-duration dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation was associated with significantly higher rates of mortality compared to shorter DAPT.

The optimal duration of DAPT has been a matter of debate since the introduction of DES. A meta-analysis using multiple analytical approaches to investigate mortality and other clinical outcomes with different DAPT strategies was conducted.

Researchers examined 31,666 patients from 10 randomized trials comparing different durations of DAPT in patients treated with DES. The primary endpoint was all-cause mortality. Secondary pre-specified endpoints included cardiac death, non-cardiac death, myocardial infarction (MI), stroke, stent thrombosis (definite or probable), major bleeding and any bleeding. DAPT duration was categorized in each study as “shorter” versus “longer,” and ?6 months versus 1 year versus ?1 year. Analyses were performed by both frequentist and Bayesian approaches.

Shorter DAPT was associated with significantly lower rates of all-cause mortality compared to longer DAPT (HR=0.82, 95 percent CI 0.69-0.98, p=0.02; number needed to treat [NNT] =325). This difference was driven by a significant reduction of non-cardiac mortality with shorter DAPT (HR=0.67, 95 percent CI 0.51-0.89, p=0.006; NNT=347). No significant difference in cardiac mortality was found between the shorter and longer strategies (HR=0.93, 95% CI 0.73-1.17, p=0.52). No significant heterogeneity across trials or between pooled trials stratified by DAPT duration was apparent.

Shorter DAPT was also associated with significantly lower rates of major bleeding (HR=0.58, 95 percent CI 0.47- 0.72, p<0.0001; NNT=166) and any bleeding (HR=0.56, 95 percent CI 0.48-0.66, p<0.0001; NNT=83) compared to longer DAPT. However, shorter DAPT was associated with significantly higher rates of MI (HR=1.51, 95 percent CI 1.28-1.77, p<0.0001; number needed to harm [NNH] =129) and definite or probable stent thrombosis (HR=2.04, 95 percent CI 1.48-2.80, p<0.0001; NNH=248) compared to longer DAPT with moderate heterogeneity across trials. Stroke rates did not vary with DAPT duration.

Additional subgroup network meta-analyses found patients treated with ?6-month DAPT and 1-year DAPT had higher risk of MI and stent thrombosis but lower risk of mortality compared to patients treated with >1-year DAPT. Patients treated with ?6-month DAPT had similar rates of mortality, MI and stent thrombosis, but lower rates of major bleeding compared to 1-year DAPT.

“This meta-analysis found that in patients treated with DES, longer DAPT was associated with a 22 percent increased rate of all-cause mortality due to a 49 percent increased rate in non-cardiac mortality, with no significant difference in cardiac mortality. These results support a short-term (3 or 6 months) DAPT strategy in most patients, especially those at low risk of recurrent coronary events and stent thrombosis, and at high risk of bleeding.” said Gregg W. Stone, M.D., the study’s senior author. Stone is co-director of the Cardiovascular Research Foundation’s Medical Research and Education Division. He is also professor of medicine at Columbia University College of Physicians and Surgeons and director of cardiovascular research and education at the Center for Interventional Vascular Therapy at New York-Presbyterian Hospital/Columbia University Medical Center.

“However, an extended DAPT strategy (longer than 1 year) may still be appropriate in selected patients in whom prevention of stent and non-stent related coronary events are likely to offset the adverse events associated with extended duration antiplatelet therapy,” he added

“Establishing the optimal duration of DAPT after DES implantation is extremely important in balancing the risks of ischemic and bleeding complications. Therefore, an individualized approach in which the benefit-risk profile for each patient should be carefully considered. Further studies are required to model the demographic, laboratory-based and genetic variables that affect the benefit vs. risk balance of prolonged DAPT that might remove the guesswork from this equation,” concluded Stone.

For more information: www.crf.org

Related Content

Xarelto Significantly Reduces Major Cardioavascular Events in Stable CAD and PAD Patients
News | Pharmaceuticals| October 18, 2017
October 18, 2017 — Results from the pivotal Phase 3 COMPASS study found that the...
News | Pharmaceuticals| October 04, 2017
October 4, 2017 — MyoKardia Inc.
News | Pharmaceuticals| September 12, 2017
September 12, 2017 — Inclisiran lowers low-density lipoprotein (LDL, or “bad”) cholesterol for up to one year in pati
Merck Announces Results of REVEAL Outcomes Study of Anacetrapib
News | Pharmaceuticals| September 11, 2017
Merck and researchers in the Clinical Trial Service Unit at the University of Oxford announced the publication and...
Statins Associated With Improved Heart Structure and Function
News | Pharmaceuticals| May 26, 2017
Statins are associated with improved heart structure and function, according to research presented at EuroCMR 2017, May...
Feature | Pharmaceuticals| May 16, 2017
May 16, 2017 – Results of a groundbreaking clinical trial demonstrate the effectiveness of a novel, fast-acting nasal
Prescribing Patterns Change Following Direct Marketing Restrictions
News | Pharmaceuticals| May 05, 2017
A study of how policies restricting pharmaceutical promotion to physicians affect medication prescribing found...
EBBINGHAUS study, evolocumab, repatha, statin therapy, cognitive issues, ACC.17 study
News | Pharmaceuticals| April 03, 2017
There is no evidence that adding a new cholesterol-lowering drug to treatment with a statin causes memory loss or other...
synthetic HDL-C injection, cholesterol, arterial plaque, heart attack patients, CARAT trial, ACC.17, clinical study
News | Pharmaceuticals| March 29, 2017
Injection of a novel form of synthetic high-density lipoprotein cholesterol (HDL-C), or good cholesterol, into the...
heart-lung machine, ECMO, levosimendan, heart failure drug, cardiovascular surgery outcomes, ACC.17 study
News | Pharmaceuticals| March 28, 2017
When used as a preventive measure during heart surgery, the heart failure drug levosimendan did not significantly...
Overlay Init