Verdoia Monica, Schaffer Alon, Barbieri Lucia, Montalescot Gilles, Collet Jean-Philippe, Colombo Antonio, Suryapranata Harry, De Luca Giuseppe
Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità," Eastern Piedmont University, Novara, Italy.
Institut de Cardiologie, Centre Hospitalier Pitié-Salpêtrière (AP-HP, ACTION Group, University Paris 6), Paris, France.
Angiology. 2016 Mar;67(3):224-38. doi: 10.1177/0003319715586500. Epub 2015 Jun 11.
Despite new-generations of drug-eluting stents (DESs), the optimal duration of dual antiplatelet therapy (DAPT) remains controversial. We performed a meta-analysis of randomized trials (RTs) evaluating the effectiveness and safety of shorter versus longer DAPT duration strategies in patients undergoing percutaneous coronary interventions with DES. Literature and main scientific session abstracts were searched. The primary end point was mortality. Secondary end points were (1) cardiovascular mortality, (2) nonfatal myocardial infarction, (3) definite/probable stent thrombosis (ST), and (4) major bleedings. We included 11 RTs (n = 32 372 patients). Shorter DAPT duration reduced mortality (odds ratio, OR [95% confidence interval, CI] = 0.85 [0.71-1], P = .05; p heterogeneity = 0.91). Similar results were observed when comparing 3 to 6 versus 12 months DAPT, while a significant increase in recurrent ischemic events was found for 6 to 12 months DAPT versus extended treatment (myocardial infarction: OR [95%CI] = 1.66 [1.37-2], P < .00001; phet = 0.13 and ST: OR [95%CI] = 2.47 [1.72-3.45], P < .00001; phet = 0.12), however, counterbalanced by a significant reduction in major bleeding (OR [95%CI] = 0.60 [0.47-0.76], P < .0001; phet = 0.38) and a trend in lower mortality. Thus, among selected patients undergoing DES implantation, a shorter DAPT strategy is associated with reduction in mortality and major bleeding but a higher risk of myocardial infarction and ST. A short duration (3-6 months) of DAPT appears as the safest strategy, while a prolonged duration (24-36 months) reduces thrombotic complications but with an excess in major bleeding complications.
尽管有新一代药物洗脱支架（DES），双联抗血小板治疗（DAPT）的最佳持续时间仍存在争议。我们对随机试验（RT）进行了一项荟萃分析，评估在接受DES经皮冠状动脉介入治疗的患者中，较短与较长DAPT持续时间策略的有效性和安全性。检索了文献和主要科学会议摘要。主要终点是死亡率。次要终点是：（1）心血管死亡率，（2）非致命性心肌梗死，（3）明确/可能的支架血栓形成（ST），以及（4）大出血。我们纳入了11项随机试验（n = 32372例患者）。较短的DAPT持续时间降低了死亡率（优势比，OR[95%置信区间，CI]=0.85[0.71 - 1]，P = 0.05；P异质性 = 0.91）。在比较3至6个月与12个月DAPT时观察到类似结果，而6至12个月DAPT与延长治疗相比，复发缺血事件显著增加（心肌梗死：OR[95%CI]=1.66[1.37 - 2]，P < 0.00001；P异质性 = 0.13；ST：OR[95%CI]=2.47[1.72 - 3.45]，P < 0.00001；P异质性 = 0.12），然而，被大出血显著减少（OR[95%CI]=0.60[0.47 - 0.76]，P < 0.0001；P异质性 = 0.38）和较低死亡率趋势所抵消。因此，在选定的接受DES植入的患者中，较短的DAPT策略与死亡率和大出血降低相关，但心肌梗死和ST风险较高。短疗程（3 - 6个月）的DAPT似乎是最安全的策略，而长疗程（24 - 36个月）可减少血栓并发症，但大出血并发症过多。
