Frederick A. Spencer, MD; Manya Prasad, MBBS; Per O. Vandvik, MD, PhD; Devin Chetan, HBA; Qi Zhou, PhD; Gordon Guyatt, MD
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0083.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Frederick A. Spencer, MD, Department of Medicine, McMaster University, Faculty of Health Sciences, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Spencer and Mr. Chetan: Department of Medicine, McMaster University, Faculty of Health Sciences, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
Dr. Prasad: Department of Community Medicine, Pt. Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Medical Road, Maharishi Dayanand University, Rohtak, Haryana 124001, India.
Dr. Vandvik: Norwegian Knowledge Centre for the Health Services (The Knowledge Centre), PO Box 7004, St. Olavs Plass, N-0130 Oslo, Norway.
Drs. Zhou and Guyatt: Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St West, Hamilton, Ontario L8S 4L8, Canada.
Author Contributions: Conception and design: G.H. Guyatt, F.A. Spencer, P.O. Vandvik.
Analysis and interpretation of the data: D. Chetan, G.H. Guyatt, M. Prasad, F.A. Spencer, P.O. Vandvik, Q. Zhou.
Drafting of the article: F.A. Spencer, P.O. Vandvik.
Critical revision for important intellectual content: D. Chetan, G.H. Guyatt, M. Prasad, P.O. Vandvik.
Final approval of the article: D. Chetan, G.H. Guyatt, M. Prasad, F.A. Spencer, P.O. Vandvik, Q. Zhou.
Statistical expertise: Q. Zhou.
Collection and assembly of data: D. Chetan, M. Prasad, F.A. Spencer.
Spencer FA, Prasad M, Vandvik PO, Chetan D, Zhou Q, Guyatt G. Longer- Versus Shorter-Duration Dual-Antiplatelet Therapy After Drug-Eluting Stent Placement: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163:118-126. doi: 10.7326/M15-0083
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Published: Ann Intern Med. 2015;163(2):118-126.
The appropriate duration of dual-antiplatelet therapy (DAPT) after drug-eluting stent (DES) placement remains controversial.
To summarize data on clinical outcomes with longer- versus shorter-duration DAPT after DES placement in adults with coronary artery disease.
Ovid MEDLINE and EMBASE, 1996 to 27 March 2015, and manual screening of references.
Randomized, controlled trials comparing longer- versus shorter-duration DAPT after DES placement.
Two reviewers screened potentially eligible articles; extracted data on populations, interventions, and outcomes; assessed risk of bias; and used the Grading of Recommendations Assessment, Development and Evaluation guidelines to rate overall confidence in effect estimates.
Among 1010 articles identified, 9 trials including 29 531 patients were eligible; data were complete for 28 808 patients. Moderate-quality evidence showed that longer-duration DAPT decreased risk for myocardial infarction (risk ratio [RR], 0.73 [95% CI, 0.58 to 0.92]) and increased mortality (RR, 1.19 [CI, 1.04 to 1.36]). High-quality evidence showed that DAPT increased risk for major bleeding (RR, 1.63 [CI, 1.34 to 1.99]).
Confidence in estimates were decreased owing to imprecision for most outcomes (particularly myocardial infarction), risk of bias from limited blinding in 7 of 9 studies, indirectness due to variability in use of first- and second-generation stents, and off-protocol use of DAPT in some studies.
Extended DAPT is associated with approximately 8 fewer myocardial infarctions per 1000 treated patients per year but 6 more major bleeding events than shorter-duration DAPT. Because absolute effects are very small and closely balanced, decisions regarding the duration of DAPT therapy must take into account patients' values and preference.
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Cardiology, Emergency Medicine, Neurology, Stroke, Acute Coronary Syndromes.
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