Dual Antiplatelet Therapy: Less Is More for Elderly Patients

A recent meta-analysis that will be published soon in JACC Intv offers evidence of benefit derived from short-term dual antiplatelet therapy for elderly patients. This is a patient group that has always been excluded from the major trials, while remaining one of the most challenging subgroups in which to balance bleeding and ischemic risks.

The main message of this work is that short-term dual antiplatelet therapy may be considered in elderly patients undergoing angioplasty with next-generation drug-eluting stents to reduce the risk of bleeding events without an increase in ischemic events.

Dual antiplatelet therapy duration has been debated since the origin of our specialty (and will probably continue to be debated indefinitely), but the tone of the discussion has escalated recently, since the publication of the DAPT and PEGASUS-TIMI 54 trials. However, elderly patients have typically been underrepresented in randomized trials, and we lack answers for this age group.

Read also: What Is the Best Antiplatelet Therapy in Primary Angioplasty at 12 Months?

This meta-analysis included 6 randomized trials (RESET, EXCELLENT, PRODIGY, OPTIMIZE, SECURITY, and ITALIC) involving 11,473 total patients assigned to short-term (3 to 6 months) or long-term (12 to 24 months) dual antiplatelet therapy. About 53.6% of all patients were younger than 65 years old, but the rest were considered elderly. Almost 90% of all patients received newer-generation drug-eluting stents.

Overall, there was no difference in the primary composite endpoint (infarction, definite/probable stent thrombosis, or stroke at 12 months) between patients who received short- versus long-term therapy, but researchers observed significant interaction between age and therapy duration.

In younger patients, the rates for the primary endpoint were higher with short-duration therapy (hazard ratio [HR]: 1.67), and this was mainly driven by the risk of infarction. On the contrary, in older patients, there was no difference in the primary endpoint between those on short- versus long-term therapy, even after adjustment.

Read also: Complex PCI: DAPT defining factor?

In terms of safety, short-term dual antiplatelet therapy was associated with a reduced risk of bleeding. This relationship was not evident in younger patients, but it was very clear in the elderly population (HR: 0.46).

This is particularly clear in the DAPT study, where the older the patient, the higher the benefit derived from short-term dual antiplatelet therapy.

Original title: Short-Term Versus Long-Term Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Elderly Patients: A Meta-Analysis of Individual Participant Data from Six Randomized Trials.

Reference: Lee S-Y et al. J Am Coll Cardiol Intv. 2018; Epub ahead of print.

We are interested in your opinion. Please, leave your comments, thoughts, questions, etc., below. They will be most welcome.