Dual Antiplatelet Therapy Duration in Patients at High Bleeding Risk

Abstract

This systematic review and meta-analysis evaluates the safety and efficacy of abbreviated dual antiplatelet therapy durations in patients at high bleeding risk undergoing percutaneous coronary intervention. QuestionAmong patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI), is an abbreviated dual antiplatelet therapy (DAPT) regimen safer and as effective as standard DAPT duration?FindingsIn this systematic review and meta-analysis of 14 randomized clinical trials, including 11 398 patients at HBR, abbreviated DAPT (1-month to 3-month) was associated with significantly lower bleeding risk compared with standard DAPT (6-month to 12-month). In comparisons with standard DAPT, abbreviated regimens were not associated with an increase in major adverse cardiovascular events, and an increased risk of major adverse cardiovascular events was observed with 1 vs 3 months of DAPT in the single trial comparing these 2 regimens, but the network estimate was nonsignificant.MeaningIn this meta-analysis, abbreviated DAPT was associated with less bleeding and, at least for 3-month regimens, was not associated with an increase in ischemic risk in patients at HBR undergoing PCI. ImportanceThe optimal duration of dual antiplatelet therapy (DAPT) in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI) remains uncertain.ObjectivesTo evaluate the safety and efficacy of abbreviated DAPT durations in patients at HBR undergoing PCI.Data SourcesPubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to October 26, 2025.Study SelectionRandomized clinical trials (RCTs) comparing abbreviated (ie, 1- to 3-month) vs standard (ie, 6- to 12-month) DAPT durations in patients at HBR without an indication for oral anticoagulation.Data Extraction and SynthesisA pairwise meta-analysis was performed to compare abbreviated (ie, 1-month to 3-month) vs standard (ie, >= 6-month) DAPT durations. A frequentist network meta-analysis was performed to compare 1-month, 3-month, and standard DAPT.Main Outcomes and MeasuresThe coprimary safety and efficacy end points were major or clinically relevant nonmajor bleeding (MCRB) and major adverse cardiovascular events (MACE; ie, a composite of cardiovascular death, myocardial infarction, or stroke).ResultsA total of 14 RCTs encompassing 11 398 patients at HBR (mean [range] age, 74.7 [68.6-80.0] years; 39.1% female and 60.9% male) were included. Compared with standard DAPT, abbreviated DAPT was associated with lower MCRB (risk ratio [RR], 0.71; 95% CI, 0.55-0.92; P = .009) and major bleeding (RR, 0.76; 95% CI, 0.59-0.99; P = .04). The risks of MACE (RR, 0.97; 95% CI, 0.81-1.16; P = .76) and its individual components did not differ between abbreviated and standard regimens. An increased risk of MACE was observed with 1-month vs 3-month DAPT in the single trial comparing these regimens, but the network estimate was nonsignificant (RR, 1.28; 95% CI, 0.96-1.72).Conclusions and RelevanceIn this systematic review and meta-analysis, for patients at HBR undergoing PCI, abbreviated DAPT was associated with a lower risk of bleeding and, at least for 3-month regimens, was not associated with an increase in fatal or nonfatal ischemic cardiovascular or cerebrovascular events compared with standard 6- to 12-month DAPT.