Optimal Duration of Dual Antiplatelet Therapy in Acute Coronary Syndrome: A Systematic Review and Meta-analysis

Abstract

Background: Dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitor is the main post-acute coronary syndrome (ACS) treatment. Current guidelines recommend 12 months of DAPT, but the optimal duration is unclear because longer therapy may reduce ischemic events but increase bleeding risk. Aim: To perform a meta-analysis to assess the efficacy and safety of various durations of DAPT in patients with ACS. Methods: A systematic review and meta-analysis following the PRISMA 2020 guidelines was conducted. Randomized controlled trials (RCTs) assessing the efficacy of drug therapies on cardiovascular outcomes were searched for using PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library. We enrolled in this study adult patients with ACS who were randomized to various DAPT durations. The primary efficacy end point was major adverse cardiovascular events (MACE), and the primary safety end point was major bleeding. Random-effects model estimates of pooled risk ratios (RRs) with 95% CIs were assessed. Study Characteristics: 18 studies including a total of 24,860 patients; Compared with 12-month DAPT, short-duration therapy (3–6 months) achieved similar rates of MACE but decreased major bleeding. DAPT longer than 12 months decreased recurrent myocardial infarction and stent thrombosis, but increased the risk of bleeding. There were no significant differences in the risk of all-cause mortality, cardiovascular mortality or stroke. There was low to moderate heterogeneity (I² = 12–34%) and no evidence of publication bias. Conclusions: In selected patients with ACS, short-duration DAPT provides similar ischemic protection but lower risk of major bleeding compared to extended DAPT which is advantageous for high-bleeding-risk patients. This reinforces an individualized based approach to DAPT duration according to ischemic and bleeding risk profiles.