ImportanceThe optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.ObjectivesTo analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis.Data SourcesMEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.Study SelectionRandomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT.Data Extraction and SynthesisThis systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).Main Outcomes and MeasuresThe primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.ResultsA total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).Conclusion and RelevanceResults of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.

中文翻译：

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急性冠脉综合征患者药物洗脱支架置入术后的短期双联抗血小板治疗


重要性接受经皮冠状动脉介入治疗 （PCI） 的急性冠脉综合征 （ACS） 患者双重抗血小板治疗 （DAPT） 的最佳持续时间仍存在争议。目的使用贝叶斯网络荟萃分析分析 DAPT 策略在 ACS 患者中的疗效和安全性。数据来源检索了从建库到 2024 年 4 月 8 日的MEDLINE、Embase、Cochrane 和 LILACS 数据库。将短期策略 （1 个月的 DAPT 后使用 P2Y12 抑制剂，3 个月的 DAPT 后使用 P2Y12 抑制剂，3 个月的 DAPT 后使用阿司匹林，以及 6 个月的 DAPT 后使用阿司匹林）与传统的 12 个月 DAPT 进行比较。资料提取和综合本系统评价和网状荟萃分析遵循系统评价和荟萃分析的首选报告项目指南。在贝叶斯随机效应网络荟萃分析中计算具有 95% 可信区间 （CrI） 的风险比 （RR）。使用累积排名下的表面 （SUCRA） 对治疗进行排名。主要结局和测量主要疗效终点是主要不良心脑血管事件 （MACCE）;主要安全终点是大出血。结果共纳入 15 项 RCT，随机分配 35 326 例 ACS 患者 （平均 [SD] 年龄，63.1 [11.1] 岁;26 954 例男性 [76.3%];11 339 例 STEMI [32.1%]）。共有 24 797 例患者 （70.2%） 接受了强效 P2Y12 抑制剂 （替格瑞洛或普拉格雷）。与 12 个月的 DAPT 相比，1 个月的 DAPT 后使用 P2Y12 抑制剂减少了大出血 （RR， 0.47;95% CrI， 0.26-0.74），MACCE 无差异 （RR， 1.00;95% CrI， 0.70-1.41）。 尽管 CrIs 很宽，但策略之间的 MACCE 发生率没有观察到显著差异。SUCRA 将 1 个月的 DAPT 队列为 P2Y12 抑制剂减少大出血的最佳选择，3 个月的 DAPT 队列中 P2Y12 抑制剂为减少 MACCE 的最佳方法 （RR，0.85;95% CrI，0.56-1.21）。结论和相关性本系统评价和网状荟萃分析的结果显示，在接受 PCI 伴 DES 的 ACS 患者中，与 12 个月的 DAPT 相比，1 个月的 DAPT 后有效的 P2Y12 抑制剂单药治疗与大出血减少相关，但 MACCE 不增加。然而，不能排除 MACCE 风险增加，3 个月的 DAPT 后进行强效 P2Y12 抑制剂单药治疗被认为是减少 MACCE 的最佳选择。由于大多数接受 P2Y12 抑制剂单药治疗的患者都在服用替格瑞洛，因此在服用氯吡格雷的患者中停用阿司匹林的安全性仍不清楚。