Short-term dual antiplatelet therapy (DAPT) followed by P2Y12 monotherapy versus traditional DAPT in patients undergoing percutaneous coronary intervention: meta-analysis and viewpoint

  • Bernhard Wernly
  • Richard Rezar
  • Paul Gurbel
  • Christian JungEmail author


The optimal duration dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is subject to debate. A short-duration DAPT (one month to three months) followed by P2Y12 monotherapy instead of standard 6 to 12 months DAPT followed by aspirin monotherapy after PCI has been suggested. We meta-analyzed studies comparing short-term (≤ 3 months) DAPT followed by P2Y12 monotherapy versus standard DAPT in patients after PCI. In total, 2304 studies were screened at title and abstract level. The primary endpoint was major bleeding. Secondary endpoints included myocardial infarction, stent thrombosis, stroke, and all-cause mortality. Study level data were analyzed. Heterogeneity was assessed using the I2 statistic. Risk rates (RR) were calculated using a random-effects model (DerSimonian and Laird) for clinical outcomes for each individual study and consecutive pooling. In total, 21970 patients from three studies were analyzed. Between P2Y12 inhibitor monotherapy versus DAPT, there were similar rates of major bleeding (RR 0.67 95%CI 0.34–1.32; p = 0.25; I2 75%), mortality (RR 0.92 95%CI 0.78–1.09; p = 0.33; I2 0%) and stroke (RR 0.97 95%CI 0.52 − 0.18; p = 0.92; I2 57%). Endpoints assessing thrombotic events showed no statistically significant difference including myocardial infarction (RR 0.99 95%CI 0.85–1.15; p = 0.86; I2 0%) and stent thrombosis (RR 1.03 95%CI 0.74–1.44; p = 0.87; I2 0%). The experimental treatment with P2Y12 monotherapy after very short-term DAPT was not superior to standard DAPT. Our meta-analysis adds insight that DAPT might be safely shortened in selected patient strategies. However, DAPT remains the gold standard for antithrombotic treatment after PCI.


P2Y12 DAPT Monotherapy Acute coronary syndrome Chronic coronary syndrome Atherosclerosis PTCA Percutaneous coronary intervention Meta-analysis 



  1. 1.
    Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Juni P, Kastrati A, Kolh P, Mauri L et al (2018) 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 39(3):213–260CrossRefGoogle Scholar
  2. 2.
    Lee SY, Hong MK, Palmerini T, Kim HS, Valgimigli M, Feres F, Colombo A, Gilard M, Shin DH, Kim JS et al (2018) Short-term versus long-term dual antiplatelet therapy after drug-eluting stent implantation in elderly patients: a meta-analysis of individual participant data from 6 randomized trials. JACC Cardiovasc Interv 11(5):435–443CrossRefGoogle Scholar
  3. 3.
    Palmerini T, Della Riva D, Benedetto U, Bacchi Reggiani L, Feres F, Abizaid A, Gilard M, Morice MC, Valgimigli M, Hong MK et al (2017) Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. Eur Heart J 38(14):1034–1043PubMedPubMedCentralGoogle Scholar
  4. 4.
    Feres F, Costa RA, Abizaid A, Leon MB, Marin-Neto JA, Botelho RV, King SB III, Negoita M, Liu M, de Paula JE et al (2013) Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial. JAMA 310(23):2510–2522PubMedGoogle Scholar
  5. 5.
    Ziada KM, Moliterno DJ (2019) Dual antiplatelet therapy: is it time to cut the cord with aspirin. JAMA 321(24):2409–2411CrossRefGoogle Scholar
  6. 6.
    Gurbel PA, Kuliopulos A, Tantry US (2015) G-protein-coupled receptors signaling pathways in new antiplatelet drug development. Arterioscler Thromb Vasc Biol 35(3):500–512CrossRefGoogle Scholar
  7. 7.
    Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Becker BJ, Sipe TA, Thacker SB (2000) Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 283(15):2008–2012CrossRefGoogle Scholar
  8. 8.
    Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269, W264CrossRefGoogle Scholar
  9. 9.
    Hahn JY, Song YB, Oh JH, Chun WJ, Park YH, Jang WJ, Im ES, Jeong JO, Cho BR, Oh SK et al (2019) Effect of P2Y12 inhibitor monotherapy vs dual antiplatelet therapy on cardiovascular events in patients undergoing percutaneous coronary intervention: the SMART-CHOICE Randomized Clinical Trial. JAMA 321(24):2428–2437CrossRefGoogle Scholar
  10. 10.
    Watanabe H, Domei T, Morimoto T, Natsuaki M, Shiomi H, Toyota T, Ohya M, Suwa S, Takagi K, Nanasato M et al (2019) Effect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: the STOPDAPT-2 randomized clinical trial. JAMA 321(24):2414–2427CrossRefGoogle Scholar
  11. 11.
    Vranckx P, Valgimigli M, Juni P, Hamm C, Steg PG, Heg D, van Es GA, McFadden EP, Onuma Y, van Meijeren C et al (2018) Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet 392(10151):940–949CrossRefGoogle Scholar
  12. 12.
    Hiatt WR, Fowkes FG, Heizer G, Berger JS, Baumgartner I, Held P, Katona BG, Mahaffey KW, Norgren L, Jones WS et al (2017) Ticagrelor versus clopidogrel in symptomatic peripheral artery disease. N Engl J Med 376(1):32–40CrossRefGoogle Scholar
  13. 13.
    Cattaneo M, Faioni EM (2012) Why does ticagrelor induce dyspnea? Thromb Haemost 108(6):1031–1036PubMedGoogle Scholar
  14. 14.
    Berwanger O, Lopes RD, Moia DDF, Fonseca FA, Jiang L, Goodman SG, Nicholls SJ, Parkhomenko A, Averkov O, Tajer C et al (2019) Ticagrelor versus clopidogrel in patients with STEMI treated with fibrinolysis: TREAT trial. J Am Coll Cardiol 73(22):2819–2828CrossRefGoogle Scholar
  15. 15.
    Baber U, Dangas G, Cohen DJ, Gibson CM, Mehta SR, Angiolillo DJ, Pocock SJ, Krucoff MW, Kastrati A, Ohman EM et al (2016) Ticagrelor with aspirin or alone in high-risk patients after coronary intervention: rationale and design of the TWILIGHT study. Am Heart J 182:125–134CrossRefGoogle Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Clinic of Internal Medicine II, Department of CardiologyParacelsus Medical UniversitySalzburgAustria
  2. 2.Inova Center for Thrombosis Research and Translational MedicineFalls ChurchUSA
  3. 3.Division of Cardiology, Pulmonology, and Vascular Medicine, Medical FacultyUniversity of DüsseldorfDüsseldorfGermany

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