Research on short-term dual antiplatelet therapy (DAPT) is still controversial. These discussions, however, seem to lead to the consensus that beyond the “category” of bleeding or ischemic risk, what is most important is a decision tailored to the patient being treated. DAPT duration should be individual, instead of standardized by a risk score.
In the MASTER-DAPT study in patients with acute coronary syndromes and high bleeding risk, a short-term DAPT did not increase the rate of ischemic events. Results did show fewer bleeding events.
Eventually, the bleeding risk is probably more relevant than the ischemic risk.
MASTER-DAPT analyzed specifically DAPT duration after angioplasty in patients at high risk for bleeding (a third of them receiving anticoagulant agents). It showed that DAPT for one month was non inferior to 3+ months, in terms of both net clinical adverse events and major adverse events. Furthermore, bleeding was less frequent with a shorter therapy.
The prespecified analysis in MASTER-DAPT included 4579 patients with acute coronary syndrome. There was no significant difference in this subgroup between both DAPT strategies.
This might seem irrelevant, but it indicates that even in patients with the highest risk for ischemic events (as those with acute coronary syndrome), a shorter therapy does not increase their risk.
Results from almost 6000 patients were pooled into a “total cohort” in STOPDAPT-2. About a third of subjects were at high risk for bleeding. All patients, either at high or standard risk for bleeding, were randomized to 1-month vs. 12-month DAPT.
The short DAPT was non-inferior for the composite endpoint of cardiovascular death, infarction, stent thrombosis, and major bleeding.
Unsurprisingly, major bleeding was higher with the 12-month treatment.
Read also: TCT 2021 | SWISS-APERO: Difference in Leaks between the Amulet and the Watchman.
A numerical increase of cardiovascular events with clopidogrel monotherapy in acute patients warrant the need for further research.
On the other hand, as regards cardiovascular and bleeding events, compared with 12-month DAPT, 1-month DAPT was consistent beyond bleeding risk and, also, in patients who underwent complex angioplasty.
Original title: STOPDAPT-2 total cohort: pooled results from two randomized controlled trials of clopidogrel monotherapy after 1-month DAPT following PCI, and subgroup analyses by ACS presentation, HBR, and complex PCI. MASTER-DAPT: a randomized trial of abbreviated antiplatelet therapy in HBR patients. Outcomes in high bleeding risk patients with high thrombotic and ischemic risk.
Reference: Obayashi Y et al. Smits PC et al. Presentados durante las sesiones científicas del TCT 2021.
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