P2Y12 Inhibitor-Based Single Antiplatelet Therapy Versus Conventional Dual Antiplatelet Therapy After Newer-Generation Drug-Eluting Stent Implantation in Chronic and Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Abstract

Background: P2Y₁₂ inhibitor-based single antiplatelet therapy (SAPT) after drug-eluting stent implantation reduces major bleeding without increasing the risk of major adverse cardiovascular and cerebral events compared with 12-month dual antiplatelet therapy (DAPT). The differential effects of P2Y₁₂ inhibitor monotherapy compared with conventional DAPT in patients with chronic coronary syndromes versus acute coronary syndromes (ACS) remain uncertain.

Methods and results: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing oral P2Y₁₂ inhibitor-based SAPT after ≤3 months DAPT versus 12-month DAPT after newer-generation drug-eluting stent implantation. Patients were categorized based on baseline presentation (chronic coronary syndromes versus ACS). The co-primary end points were major bleeding and major adverse cardiovascular and cerebral events, a composite of all-cause death, myocardial infarction, or ischemic stroke. A total of 43 945 (ACS, 28 360, 65%) patients from 7 randomized controlled trials were included. At a median follow-up of 12 months, P2Y₁₂ inhibitor-based SAPT was associated with a lower risk of major bleeding (risk ratio [RR], 0.63 [95% CI, 0.48-0.82]; P<0.001) compared with 12-month DAPT. The risk of major bleeding was significantly lower among patients with ACS (RR, 0.55 [95% CI, 0.40-0.75]; P<0.001). Compared with standard DAPT, P2Y₁₂ inhibitor-based SAPT was associated with a similar risk of major adverse cardiovascular and cerebral events (RR, 0.98 [95%CI, 0.87-1.11]; P=0.74) among patients with chronic coronary syndromes and ACS. There was no significant interaction between treatment effect and baseline presentation.

Conclusions: Compared with 12-month DAPT, P2Y₁₂ inhibitor-based SAPT after newer-generation drug-eluting stent implantation is associated with a lower risk of major bleeding without increasing the risk of major adverse cardiovascular and cerebral events, a difference primarily driven by patients with ACS.

Registration: URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023239341.