Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy.
Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
JACC Cardiovasc Interv. 2022 Feb 14;15(3):268-277. doi: 10.1016/j.jcin.2021.11.028.
The aim of this study was to compare short dual antiplatelet therapy (DAPT) and de-escalation in a network meta-analysis using standard DAPT as common comparator.
In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), shortening DAPT and de-escalating to a lower potency regimen mitigate bleeding risk. These strategies have never been randomly compared.
Randomized trials of DAPT modulation strategies in patients with ACS undergoing PCI were identified. All-cause death was the primary outcome. Secondary outcomes included net adverse cardiovascular events (NACE), major adverse cardiovascular events, and their components. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on the basis of posterior probability. Sensitivity analyses were performed to explore sources of heterogeneity.
Twenty-nine studies encompassing 50,602 patients were included. The transitivity assumption was fulfilled. In the frequentist indirect comparison, the risk ratio (RR) for all-cause death was 0.98 (95% CI: 0.68-1.43). De-escalation reduced the risk for NACE (RR: 0.87; 95% CI: 0.70-0.94) and increased major bleeding (RR: 1.54; 95% CI: 1.07-2.21). These results were consistent in the Bayesian meta-analysis. De-escalation displayed a >95% probability to rank first for NACE, myocardial infarction, stroke, stent thrombosis, and minor bleeding, while short DAPT ranked first for major bleeding. These findings were consistent in node-split and multiple sensitivity analyses.
In patients with ACS undergoing PCI, there was no difference in all-cause death between short DAPT and de-escalation. De-escalation reduced the risk for NACE, while short DAPT decreased major bleeding. These data characterize 2 contemporary strategies to personalize DAPT on the basis of treatment objectives and risk profile.
本研究旨在通过使用标准 DAPT 作为共同比较，在网络荟萃分析中比较短期双联抗血小板治疗（DAPT）和降级治疗。
在接受经皮冠状动脉介入治疗（PCI）的急性冠脉综合征（ACS）患者中，缩短 DAPT 并降低至较低强度方案可降低出血风险。这些策略从未被随机比较过。
确定了接受 PCI 的 ACS 患者中 DAPT 调制策略的随机试验。全因死亡是主要结局。次要结局包括净不良心血管事件（NACE）、主要不良心血管事件及其组成部分。进行了频率论和贝叶斯网络荟萃分析。根据后验概率对治疗方法进行排序。进行敏感性分析以探索异质性的来源。
共纳入 50602 例患者的 29 项研究。满足传递性假设。在频率论间接比较中，全因死亡的风险比（RR）为 0.98（95%可信区间：0.68-1.43）。降级治疗降低了 NACE（RR：0.87；95%可信区间：0.70-0.94）的风险，并增加了大出血（RR：1.54；95%可信区间：1.07-2.21）。贝叶斯荟萃分析的结果是一致的。降级治疗在 NACE、心肌梗死、卒中和支架血栓形成和轻微出血方面具有超过 95%的概率排名第一，而短期 DAPT 在大出血方面排名第一。节点分裂和多次敏感性分析的结果一致。
在接受 PCI 的 ACS 患者中，短期 DAPT 和降级治疗在全因死亡方面没有差异。降级治疗降低了 NACE 的风险，而短期 DAPT 降低了大出血的风险。这些数据描述了两种基于治疗目标和风险特征来个体化 DAPT 的当代策略。
