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Thromb Haemost 2023; 123(08): 773-792
DOI: 10.1055/s-0043-57030
Cellular Haemostasis and Platelets

Comparison of De-escalation of DAPT Intensity or Duration in East Asian and Western Patients with ACS Undergoing PCI: A Systematic Review and Meta-analysis

Diana A. Gorog 
1   Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
2   Centre for Health Services and Clinical Research, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
,
Visvesh Jeyalan
3   Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
,
Rafaella I. L. Markides
4   University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridgeshire, United Kingdom
,
Eliano P. Navarese
5   Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
6   Department of Cardiology, Faculty of Medicine, University of Alberta, Edmonton, Canada
,
Young-Hoon Jeong 
7   CAU Thrombosis and Biomarker Center, Chung-Ang University, Gwangmyeong Hospital, Seoul, Republic of Korea
8   Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
,
Mohamed Farag 
2   Centre for Health Services and Clinical Research, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
3   Department of Cardiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
› Author Affiliations Funding None.
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Abstract

Background Guideline-recommended dual antiplatelet therapy (DAPT; aspirin plus prasugrel/ticagrelor) for 12 months in acute coronary syndrome (ACS) patients increases bleeding, with East Asians (EAs) exhibiting higher bleeding and lower ischemic risk, compared with non-East Asians (nEAs). We sought to compare DAPT “de-escalation” strategies in EA and nEA populations.

Methods A systematic review and meta-analysis of randomized controlled trials assessing reduction of DAPT intensity or duration in ACS patients undergoing percutaneous coronary intervention, in EA and nEA, was performed using a random-effects model.

Results Twenty-three trials assessed reduction of DAPT intensity (n = 12) or duration (n = 11). Overall, reduced DAPT intensity attenuated major bleeding (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65–0.94, p = 0.009), without impacting net adverse cardiovascular events (NACE) or major adverse cardiovascular events (MACE). In nEA, this increased MACE (OR: 1.20, 95% CI: 1.09–1.31, p < 0.0001) without impacting NACE or bleeding; while in EA, it reduced major bleeding (OR: 0.71, 95% CI: 0.53–0.95, p = 0.02) without affecting NACE or MACE. Overall, abbreviation of DAPT duration reduced NACE (OR: 0.90, 95% CI: 0.82–0.99, p = 0.03) due to major bleeding (OR: 0.69, 95% CI: 0.53–0.99, p = 0.006), without impacting MACE. In nEA, this strategy did not impact NACE, MACE, or major bleeding; while in EA, it reduced major bleeding (OR: 0.60, 95% CI: 0.4–0.91, p = 0.02) without impacting NACE or MACE.

Conclusion In EA, reduction of DAPT intensity or duration can minimize bleeding, without safety concerns. In nEA, reduction of DAPT intensity may incur an ischemic penalty, while DAPT abbreviation has no overall benefit.

Keywords

dual antiplatelet therapy - de-escalation - acute coronary syndrome - bleeding - East Asian

Supplementary Material



Publication History

Received: 21 January 2023

Accepted: 17 March 2023

Article published online:
18 April 2023

© 2023. Thieme. All rights reserved.

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