Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Independent Information Specialist, Ottawa, Ontario, Canada.
Can J Cardiol. 2019 Aug;35(8):1039-1046. doi: 10.1016/j.cjca.2019.01.021. Epub 2019 Feb 6.
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention with stenting requires consideration of patient characteristics, and decision makers require a comprehensive overview of the evidence.
We performed an umbrella review of systematic reviews (SRs) of randomized controlled trials of extended DAPT (> 12 months) compared with DAPT for 6 to 12 months after percutaneous coronary intervention with stenting. Outcomes of interest were death, myocardial infarction (MI), stroke, stent thrombosis, major adverse cardiac and cerebrovascular events, bleeding, and urgent revascularization. We aimed to assess the evidence of benefits and harms among clinically important subgroups (eg, elderly patients, those with diabetes, prior MI, acute coronary syndrome). We assessed the quality of the included reviews by use of A Measurement Tool to Assess Systematic Reviews (AMSTAR).
Sixteen SRs involving 8 randomized controlled trials were included. Most scored 7 or more points on the AMSTAR checklist. There was no significant difference in outcomes with extended DAPT compared with 6 months of DAPT in most SRs, with the exception of an increased risk of major bleeding. Compared with 12 months, extended DAPT may reduce the risk of MI and stent thrombosis; however, the findings were not consistent across all reviews. There have been conflicting reports of an increased risk of death with extended DAPT. Few SRs assessed outcomes among patient subgroups.
Extended DAPT may reduce the risk of MI and stent thrombosis but increase the risk of major bleeding and death. Whether the effects of extended DAPT are consistent across patient subgroups is unclear, and future SRs should address this knowledge gap.
经皮冠状动脉介入治疗（PCI）置入支架后双联抗血小板治疗（DAPT）的最佳持续时间需要考虑患者特征，决策者需要全面了解证据。
我们对延长 DAPT（>12 个月）与 PCI 置入支架后 6-12 个月 DAPT 进行的随机对照试验的系统评价（SR）进行了伞式评价。感兴趣的结局包括死亡、心肌梗死（MI）、卒、支架血栓形成、主要不良心脏和脑血管事件、出血和紧急血运重建。我们旨在评估在临床重要亚组（如老年患者、糖尿病患者、既往 MI、急性冠状动脉综合征）中获益和危害的证据。我们使用评估系统评价的 A 测量工具（AMSTAR）评估纳入的综述的质量。
纳入了 16 项涉及 8 项随机对照试验的 SR。大多数在 AMSTAR 清单上得分为 7 分或以上。大多数 SR 中，与 6 个月 DAPT 相比，延长 DAPT 并未显著改善结局，除了大出血风险增加。与 12 个月相比，延长 DAPT 可能降低 MI 和支架血栓形成的风险；然而，并非所有综述都得出一致的结论。有报道称延长 DAPT 可能增加死亡风险。少数 SR 评估了患者亚组的结局。
延长 DAPT 可能降低 MI 和支架血栓形成的风险，但增加大出血和死亡的风险。延长 DAPT 的效果在患者亚组中是否一致尚不清楚，未来的 SR 应解决这一知识空白。
