TY - JOUR
T1 - Bleeding-Related Deaths in Relation to the Duration of Dual-Antiplatelet Therapy After Coronary Stenting
AU - Palmerini, Tullio
AU - Bacchi Reggiani, Letizia
AU - Della Riva, Diego
AU - Romanello, Mattia
AU - Feres, Fausto
AU - Abizaid, Alexandre
AU - Gilard, Martine
AU - Morice, Marie Claude
AU - Valgimigli, Marco
AU - Hong, Myeong Ki
AU - Kim, Byeong Keuk
AU - Jang, Yangsoo
AU - Kim, Hyo Soo
AU - Park, Kyung Woo
AU - Colombo, Antonio
AU - Chieffo, Alaide
AU - Ahn, Jung Min
AU - Park, Seung Jung
AU - Schüpke, Stefanie
AU - Kastrati, Adnan
AU - Montalescot, Gilles
AU - Steg, Philippe Gabriel
AU - Diallo, Abdourahmane
AU - Vicaut, Eric
AU - Helft, Gerard
AU - Biondi-Zoccai, Giuseppe
AU - Xu, Bo
AU - Han, Yaling
AU - Genereux, Philippe
AU - Bhatt, Deepak L.
AU - Stone, Gregg W.
N1 - Publisher Copyright:
© 2017 American College of Cardiology Foundation
PY - 2017/4/25
Y1 - 2017/4/25
N2 - Background Although some randomized controlled trials (RCTs) and meta-analyses have suggested that prolonged dual-antiplatelet therapy (DAPT) may be associated with increased mortality, the mechanistic underpinnings of this association remain unclear. Objectives The aim of this study was to analyze the associations among bleeding, mortality, and DAPT duration after drug-eluting stent implantation in a meta-analysis of RCTs. Methods RCTs comparing different DAPT durations after drug-eluting stent placement were sought through the MEDLINE, Embase, and Cochrane databases and the proceedings of international meetings. Deaths were considered possibly bleeding related if occurring within 1 year of the episodes of bleeding. Primary analysis was by intention-to-treat. Secondary analysis was performed in a modified intention-to-treat population in which events occurring when all patients were on DAPT were excluded. Results Individual patient data were obtained for 6 RCTs, and aggregate data were available for 12 RCTs. Patients with bleeding had significantly higher rates of mortality compared with those without, and in a time-adjusted multivariate analysis, bleeding was an independent predictor of mortality occurring within 1 year of the bleeding episode (hazard ratio: 6.93; 95% confidence interval: 4.53 to 10.60; p < 0.0001). Shorter DAPT was associated with lower rates of all-cause death compared with longer DAPT (hazard ratio: 0.85; 95% confidence interval: 0.73 to 1.00; p = 0.05), which was driven by lower rates of bleeding-related deaths with shorter DAPT compared with prolonged DAPT (hazard ratio: 0.65; 95% confidence interval: 0.43 to 0.99; p = 0.04). Mortality unrelated to bleeding was comparable between the 2 groups. Similar results were apparent in the modified intention-to-treat population. Conclusions Bleeding was strongly associated with the occurrence of mortality within 1 year after the bleeding event. Shorter compared with longer DAPT was associated with lower risk for bleeding-related death, a finding that may underlie the lower all-cause mortality with shorter DAPT in the RCTs of different DAPT durations after DES.
AB - Background Although some randomized controlled trials (RCTs) and meta-analyses have suggested that prolonged dual-antiplatelet therapy (DAPT) may be associated with increased mortality, the mechanistic underpinnings of this association remain unclear. Objectives The aim of this study was to analyze the associations among bleeding, mortality, and DAPT duration after drug-eluting stent implantation in a meta-analysis of RCTs. Methods RCTs comparing different DAPT durations after drug-eluting stent placement were sought through the MEDLINE, Embase, and Cochrane databases and the proceedings of international meetings. Deaths were considered possibly bleeding related if occurring within 1 year of the episodes of bleeding. Primary analysis was by intention-to-treat. Secondary analysis was performed in a modified intention-to-treat population in which events occurring when all patients were on DAPT were excluded. Results Individual patient data were obtained for 6 RCTs, and aggregate data were available for 12 RCTs. Patients with bleeding had significantly higher rates of mortality compared with those without, and in a time-adjusted multivariate analysis, bleeding was an independent predictor of mortality occurring within 1 year of the bleeding episode (hazard ratio: 6.93; 95% confidence interval: 4.53 to 10.60; p < 0.0001). Shorter DAPT was associated with lower rates of all-cause death compared with longer DAPT (hazard ratio: 0.85; 95% confidence interval: 0.73 to 1.00; p = 0.05), which was driven by lower rates of bleeding-related deaths with shorter DAPT compared with prolonged DAPT (hazard ratio: 0.65; 95% confidence interval: 0.43 to 0.99; p = 0.04). Mortality unrelated to bleeding was comparable between the 2 groups. Similar results were apparent in the modified intention-to-treat population. Conclusions Bleeding was strongly associated with the occurrence of mortality within 1 year after the bleeding event. Shorter compared with longer DAPT was associated with lower risk for bleeding-related death, a finding that may underlie the lower all-cause mortality with shorter DAPT in the RCTs of different DAPT durations after DES.
KW - drug-eluting stent
KW - dual antiplatelet therapy
KW - mortality
UR - https://www.scopus.com/pages/publications/85018395760
U2 - 10.1016/j.jacc.2017.02.029
DO - 10.1016/j.jacc.2017.02.029
M3 - Article
C2 - 28427576
AN - SCOPUS:85018395760
SN - 0735-1097
VL - 69
SP - 2011
EP - 2022
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 16
ER -