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

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 (EA) exhibiting higher bleeding and lower ischaemic risk, compared to non-East Asians (nEA). We sought to compare DAPT “de-escalation” strategies in EA and nEA populations.
Methods
A systematic review and meta-analysis of randomised 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, pOverall, 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; whilst 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 minimise bleeding, without safety concerns. In nEA, reduction of DAPT intensity may incur an ischaemic penalty, whilst DAPT abbreviation has no overall benefit.