Meta-analysis of the efficacy of the DAPT score to decide on treatment duration
Meta-Analysis of Studies Examining the External Validity of the DAPT Score
Literature - Witberg G, Zusman O, Yahav D et al., - Eur Heart J Cardiovasc Pharmacother 2019 https://doi.org/10.1093/ehjcvp/pvz075Introduction and methods
The optimal duration of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) is an often debated issue. As DAPT is extended, a balance needs to be found between reducing ischemic events (such as stent thrombosis (ST) and myocardial infarction (MI)) on one side and increasing bleeding risk on the other side, while risk of mortality is unaffected [1]. Current US and European practice guidelines strongly advise customization of DAPT duration according to the patient’s individual relative risk for ischemia vs. bleeding hazards [2,3]. The DAPT score has been developed for the evaluation of these competing risks and to aid clinicians in making a choice for DAPT duration [4].
Several studies have examined the external validity of the DAPT score, but results were inconsistent and showed no potential benefit from using the DAPT score decision tool [5-9]. However, most of these studies had a moderate sample size, thus, it is possible that negative results are due to low statistical power. This meta-analysis therefore set out to examine the external validity of the DAPT score and/or its decision tool.
Seven studies (total sample size 77,274 patients) were included in this meta-analysis [4-10]. The follow-up ranged from 9-24 months (median 18 months). The primary efficacy outcome was the composite of MI or ST, and the primary safety efficacy was bleeding events. The main analysis concerned the efficacy and safety outcomes of post PCI patients treated with extended (>12 up to 24 months) vs. standard (6-12 months) DAPT duration stratified by DAPT score stratum (DAPT score <2= low score stratum, DAPT score ≥2 = high score stratum).
Main results
- High DAPT score (≥2) was associated with increased risk for MI/ST (OR 1.54, 95%CI 1.41-1.69, P<0.01, I²=45%, 7 studies, n=77,274) and reduced risk for bleeding (OR 0.84, 95%CI 0.73-0.97, P=0.01 I²=0%, 7 studies, n=77272).
- In the high DAPT score stratum (≥2), extended as compared to standard DAPT duration was associated with lower risk for MI/ST (OR 0.67, 95% CI 0.48-0.94, P=0.02 I²=0%, 4 studies, n=6,173), and no increase in bleeding risk (OR 1.04, 95% CI 0.65-1.66, P=0.88 I²=0%, 4 studies, n=6,173).
- In the low DAPT score stratum (<2), extended DAPT duration was associated with no difference in risk for MI/ST (OR 1.04, 95% CI 0.76-1.43, P=0.80 I²=24%, 4 studies, n=9,948), and increased risk for bleeding (OR 1.58, 95% CI 1.15-2.15, P<0.01 I²=5%, 4 studies, n=9,948).
Conclusion
This meta-analysis of the efficacy and safety of extended vs standard DAPT in post PCI patients stratified by DAPT score strata, suggests that the DAPT score is useful for stratifying patients into risk strata for ischemic and bleeding events, and for the choice of DAPT duration. For patients with a high DAPT score, extended DAPT duration resulted in reduced ischemic risk with no increase in bleeding risk. For low DAPT score patients, extended therapy led to no difference in ischemic risk, but increased risk for bleeding.
References
1. Bittl JA, Baber U, Bradley SM et al., Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68:1116-39.
2. Levine GN, Bates ER, Bittl JA et al.,2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68(10):1082-115.
3. Valgimigli M, Bueno H, Byrne RA et al.,2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017.
4. Yeh RW, Secemsky EA, Kereiakes DJ et al., Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention. JAMA. 2016 ;315(16):1735-49.
5. Yoshikawa Y, Shiomi H, Watanabe H et al., Validating Utility of Dual Antiplatelet Therapy Score in a Large Pooled Cohort From 3 Japanese Percutaneous Coronary Intervention Studies. Circulation. 2018 Feb 6;137(6):551-562.
6. Ueda P, Jernberg T, James S et al., External Validation of the DAPT Score in a Nationwide Population. J Am Coll Cardiol. 2018;72(10):1069-1078.
7. Harada Y, Michel J, Lohaus R et al., Validation of the DAPT score in patients randomized to 6 or 12 months clopidogrel after predominantly second-generation drug-eluting stents. Thromb Haemost. 2017;117(10).
8. Piccolo R, Gargiulo G, Franzone A et al., Use of the Dual-Antiplatelet Therapy Score to Guide Treatment Duration After Percutaneous Coronary Intervention. Ann Intern Med. 2017;167(1):17-25.
9. Witberg G, Zusman O, Bental T et al., Validation of the DAPT score in real-world patients undergoing coronary stent implantation. Int J Cardiol. 2019 Aug 21. pii: S0167-5273(19)32413-1. doi: 10.1016/j.ijcard.2019.08.044. [Epub ahead of print]
10. Brener SJ, Kirtane AJ, Rinaldi MJ et al., Prediction of Ischemic and Bleeding Events Using the Dual Antiplatelet Therapy Score in an Unrestricted Percutaneous Coronary Intervention Population. Circ Cardiovasc Interv. 2018;11(10):e006853.
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