Jul 2026· Catheterization and cardiovascular interventions· Vol 108, pp. 946 - 965· 0 citations· 104 references
Medicine
TL;DR
Current data support replacing one‐size‐fits‐all 12‐month DAPT with risk‐guided algorithms for post‐PCI antithrombotic therapy, and evaluate bleeding and ischemic risk scores.
Abstract
Antithrombotic therapy after percutaneous coronary intervention (PCI) is shifting from fixed 12‐month dual antiplatelet therapy (DAPT) to risk‐stratified, patient‐centered regimens. In this systematic review (80 studies; >330,000 patients), we compare personalized versus fixed DAPT strategies, evaluate abbreviated DAPT in high‐bleeding‐risk (HBR) populations, and evaluate bleeding and ischemic risk scores. Personalized strategies, including genotype‐guided therapy, ultra‐short DAPT (≤1 month) with P2Y12 monotherapy, and 3‐month DAPT, substantially reduce bleeding (often by roughly 25%−65%); ischemic risk after de‐escalation is heterogeneous across populations and strategies, with most trials showing neutrality and one (STOPDAPT‐2 ACS) signaling increased myocardial infarction (MI) when aspirin was withdrawn after 1–2 months of clopidogrel‐based DAPT in acute coronary syndrome (ACS). In HBR patients, 1 to 3‐month DAPT followed by P2Y12 monotherapy lowers major bleeding by up to 65% and may reduce cardiovascular mortality, without increased MI or stent thrombosis in most trials, although ischemic signals varied by population and strategy. In atrial fibrillation, avoiding prolonged triple therapy reduces bleeding by approximately 30%. In ACS, prasugrel is favored over ticagrelor for ischemic outcomes; ARC‐HBR, PRECISE‐DAPT, and the newer PRECISE‐HBR scores show moderate discrimination (c‐statistic 0.64–0.75). Contemporary data therefore support replacing one‐size‐fits‐all 12‐month DAPT with risk‐guided algorithms for post‐PCI antithrombotic therapy.
Individualized DAPT de-escalation, guided by dynamic risk assessment using PRECISE‑DAPT and ARC-HBR criteria, optimizes net clinical benefit and should focus on precision antithrombotic strategies in Chinese populations and high-risk subgroups.
Background Despite widespread adoption of abbreviated (<12 months) dual antiplatelet therapy (DAPT) strategies after percutaneous coronary intervention (PCI), the optimal threshold for DAPT abbreviation remains undefined. Methods We conducted a network meta-analysis of randomized controlled trials (RCTs) evaluating various abbreviated DAPT durations in patients undergoing PCI with contemporary drug-eluting stents (DES). We searched PubMed, Embase, and Scopus from January 2008 through March 21, 2026. The efficacy and safety outcomes were major adverse cardiovascular events (MACE) and major bleeding, respectively. Relative treatment effects were estimated using risk ratios (RR) with 95% confidence intervals (CI) using random-effects models. Treatment ranking was assessed using surface under the cumulative ranking curve (SUCRA). The study protocol was registered on PROSPERO (CRD420261349664). Findings Twenty-eight RCTs comprising 84,325 patients were included. Compared with 12-month DAPT, abbreviated strategies (1-, 3-, and 6-month) were not associated with a significant difference in MACE (1-month: RR 1.03 [95% CI 0.88–1.22]; 3-month: RR 0.95 [95% CI 0.82–1.10]; 6-month: RR 1.06 [95% CI 0.88–1.27]). In contrast, these shorter durations were associated with significantly reduced major bleeding (1-month: RR 0.59 [95% CI 0.42–0.82]; 3-month: RR 0.64 [95% CI 0.49–0.84]), with a consistent trend for 6-month DAPT (RR 0.68, 95% CI: 0.46–1.00). SUCRA rankings indicated that the 3-month DAPT strategy ranked highest for MACE (lowest ischemic risk); whereas the 1-month strategy ranked highest for major bleeding (lowest bleeding risk), followed by the 3-month strategy. Conclusion Shorter DAPT durations (1 & 3 months) were associated with reduced bleeding without evidence of increased ischemic risk compared with the conventional 12-month strategy. Among the abbreviated strategies, the 3-month regimen consistently demonstrated the most favorable overall profile across analyses, suggesting it may represent a pragmatic threshold for DAPT abbreviation. However, these findings should be interpreted cautiously given the absence of statistically significant differences in efficacy and the limitations inherent to study-level network meta-analysis.
Admire Hlupeni, Mehran Jalilzadehbinazar, Rayvlin J. Liceralde et al.· PLoS ONE· 0 citations
BACKGROUND
In patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), 12-month dual antiplatelet therapy (DAPT) has long been the standard of care. However, emerging evidence suggests that discontinuing aspirin early while maintaining P2Y12 inhibitor monotherapy may reduce bleeding without compromising ischemic protection. We performed a systematic review and meta-analysis to evaluate the impact of early aspirin discontinuation compared with standard 12-month DAPT on clinical outcomes after PCI for ACS.
METHODS
A meta-analysis was performed including randomized clinical trials and post-hoc analyses of randomized trials comparing early aspirin discontinuation (within 1-3 months post-PCI) to standard 12-month DAPT in ACS populations. The major endpoints were a composite of net adverse clinical events (NACE), major adverse cardiovascular events (MACE), all cause and cardiovascular mortality, MI, stroke, stent thrombosis (ST), target vessel revascularization (TVR), and bleeding. A random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using I² statistics.
RESULTS
Nine studies were included, encompassing 31,505 patients (15,700 early discontinuation; 15,805 standard DAPT). Across the 9 included studies, early aspirin discontinuation was associated with a significant reduction in NACE compared with standard DAPT (OR 0.77, 95% CI 0.65-0.91; p = 0.002) due to reduction in BARC ≥2 bleeding [0.41; 0.32-0.52; P <0.00001]. Early aspirin discontinuation, compared to 12-month DAPT resulted in similar risk of MACE [0.88; 0.73-1.07; P =0.19], all-cause mortality [0.84; 0.69-1.03; P= 0.09], cardiovascular mortality [1.02; 0.74-1.41; P = 0.92], MI [0.98; 0.77-1.25; P=0.87], stroke [0.97; 0.73-1.29; P =0.82], ST [1.29; 0.83-2.0; P=0.26] and TVR [1.00; 0.79-1.27; P = 1.00].
CONCLUSION
In ACS patients treated with PCI, early discontinuation of aspirin while maintaining P2Y12 inhibitor monotherapy appears to reduce adverse clinical events compared with standard 12-month DAPT. These findings show net benefit of following early aspirin discontinuation strategy due to reduction in major bleeding events without jeopardizing ischemic outcomes.
Abhigna Kolupoti, E. Itaya, Bryan O. Perez Martinez et al.· American Journal of Cardiolo...· 0 citations
BACKGROUND
Patients at high bleeding risk (HBR) presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI) have competing hazards of ischemic and bleeding events. In unselected ACS populations, trials of unguided de-escalation of P2Y12 inhibition reduce bleeding without excess ischemia; however, HBR patients were largely underrepresented in these studies. Comparative evidence across multiple de-escalation regimens in this vulnerable cohort is currently lacking.
STUDY DESIGN
DESC-HBR is a prospective, multicenter, randomized, open-label trial with blinded endpoint adjudication enrolling 200 HBR patients (PRECISE-DAPT ≥25 or ARC-HBR criteria) at 30 ± 7 days after ACS-PCI. Following one month of dual antiplatelet therapy (DAPT) with prasugrel 10 mg once daily or ticagrelor 90 mg twice daily, on a background of aspirin 100 mg, patients are randomized (1: 1:1:1) to clopidogrel 75 mg once daily, prasugrel 5 mg once daily, ticagrelor 60 mg twice daily, or continuation of full-dose potent therapy. The primary endpoint is the proportion of patients achieving optimal platelet reactivity (VerifyNow PRU 85-208) at 14 ± 2 days post-randomization, 2-h after maintenance dose. Key secondary outcomes include BARC bleeding, net adverse clinical events, quality of life and adherence. Pharmacodynamic profiling incorporates VerifyNow and Total Thrombus Formation Analysis (T-TAS). A total sample of 200 patients allows >80% power to detect superiority of each de-escalation arm versus control (α = 0.017).
CONCLUSIONS
DESC-HBR is the first randomized trial directly comparing multiple P2Y12 inhibitor de-escalation strategies in HBR patients post-ACS. By integrating pharmacodynamic, clinical, and patient-reported outcomes, it will provide information to guide individualized antiplatelet strategies balancing ischemic protection and bleeding mitigation in HBR patients.
CLINICAL TRIAL REGISTRATION UNIQUE IDENTIFIER
NCT05903976, EudraCT 2023-000029-10.
Francesco Costa, Gianpiero Vizzari, S. Zecchino et al.· Cardiovascular Revasculariza...· 0 citations
BACKGROUND
The optimal duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) remains uncertain. Advances in stent design and the use of potent P2Y₁₂ inhibitors have reduced thrombotic risk, raising questions about whether prolonged DAPT continues to provide incremental benefit.
METHODS
We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) enrolling exclusively ACS patients undergoing PCI who were randomized to 3-month versus 12-month DAPT. Coprimary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and clinically relevant bleeding (CRB). Secondary outcomes included all-cause mortality, myocardial infarction, stroke, stent thrombosis, target-vessel revascularization, and net adverse clinical events (NACE; MACCE + CRB). Trial sequential analysis (TSA) was performed to evaluate the conclusiveness of evidence for each coprimary outcome.
RESULTS
Seven RCTs encompassing 17,515 patients (mean age 63 years; 31% women; 45% STEMI) were included. Abbreviated 3-month DAPT did not differ from 12-month therapy for MACCE (5.6% vs 5.7%; risk ratio [RR], 0.96; 95% CI, 0.79-1.17; I2 = 44%), but significantly reduced CRB (3.0% vs 4.9%; RR, 0.62; 95% CI, 0.50-0.76; I2 = 31%), corresponding to an absolute risk reduction of 1.9% and number needed to treat of 52. NACE was lower with abbreviated therapy (7.9% vs 9.7%; RR, 0.81; 95% CI, 0.66-1.00). TSA crossed the futility boundary for MACCE and the benefit boundary for CRB, indicating conclusive evidence for bleeding reduction and futility for ischemic benefit.
CONCLUSIONS
Among ACS patients treated with contemporary DES, 3-month DAPT followed by monotherapy significantly reduces bleeding without increasing ischemic events. TSA confirms the conclusiveness of current evidence, supporting abbreviated DAPT as a safe and effective default strategy in appropriately selected ACS patients.
REGISTRATION
The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with unique identifier CRD420251143351 and URL: https://www.crd.york.ac.uk/prospero/search.
C. Chinnatambi, Abdul Rahaman Ottun, Louise Sakowski et al.· Cardiovascular Revasculariza...· 0 citations
Background Coronary artery ectasia (CAE) is characterized by abnormal coronary dilation and slow flow, predisposing patients to thrombotic complications. Optimal long-term antithrombotic strategies for CAE remain undefined. This study aimed to evaluate the efficacy and safety of low-dose rivaroxaban combined with single antiplatelet therapy in patients with CAE. Methods In this single-center retrospective cohort study, 312 patients with CAE were enrolled and followed for 36 months. Patients received either single antiplatelet therapy alone or in combination with low-dose rivaroxaban. Propensity score matching (1:1) was performed to balance baseline characteristics. The primary endpoint was major adverse cardiovascular events (MACE). Secondary analyses included changes in thrombotic, inflammatory, and myocardial injury biomarkers. Cox proportional hazards models, inverse probability weighting, competing risk models, and sensitivity analyses were conducted to assess robustness. Results After propensity score matching (124 vs. 124), combination therapy was associated with a significantly lower risk of 36-month MACE compared with antiplatelet therapy alone (8.1% vs. 21.8%; HR = 0.34, 95% CI: 0.19–0.62; P < 0.001), corresponding to an absolute risk reduction of 13.7% and a number needed to treat of 7.3. The benefit was more pronounced in patients with diffuse ectasia (Markis I/II: HR = 0.21, 95% CI: 0.09–0.49; interaction P = 0.02) and elevated baseline D-dimer (≥0.8 mg/L: HR = 0.18, 95% CI: 0.08–0.41; interaction P = 0.01). Improvements in D-dimer, inflammatory markers, and myocardial injury biomarkers were greater in the combination group. Total bleeding rates were not significantly different between groups, and no fatal bleeding occurred. Net clinical benefit favored combination therapy. Results remained consistent across multiple sensitivity analyses. A simple risk prediction model based on D-dimer, Markis classification, and treatment regimen was developed in the same cohort (C-index 0.78) but has not been externally validated. Conclusions In patients with CAE, low-dose rivaroxaban combined with single antiplatelet therapy was associated with lower long-term MACE risk without a significant increase in major bleeding. The benefit appeared particularly pronounced in patients with diffuse ectasia and higher thrombotic burden. The simple predictive model based on D-dimer, Markis classification, and treatment regimen may aid in individualized antithrombotic decision-making, but requires external validation.
Meng Feng, Yunjie Wu, Chaoqing Xie et al.· Frontiers in Cardiovascular...· 0 citations
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