Dual antiplatelet therapy duration after percutaneous coronary intervention with contemporary drug-eluting stents: A systematic review and network meta-analysis of randomized trials

Abstract

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.