Background and Rationale
Dual antiplatelet therapy (DAPT), the combination of a P2Y12 inhibitor with ASA, is routinely given following percutaneous coronary intervention (PCI) with stenting with the aim of preventing stent thrombosis and major adverse cardiovascular events. Extending DAPT beyond 12 months may reduce the risk of late stent thrombosis but may be associated with an increased risk of bleeding and death.1 Guidelines by the Canadian Cardiovascular Society recommend the use of DAPT for 12 months after PCI,2 while the European Society of Cardiology recommends DAPT for up to 12 months following PCI.3 Furthermore, recent guidelines by the American College of Cardiology and American Heart Association1 recommend that DAPT be given for at least six to 12 months in most clinical settings, and state that it may be reasonable to prolong DAPT beyond 12 months for some patients.
The optimal duration of DAPT to balance the risk and harms following PCI is unclear. In clinical practice, some patients receive DAPT beyond 12 months (extended DAPT). In some jurisdictions, reimbursement of P2Y12 inhibitors after stenting may be limited to 12 months, which may impact access to DAPT for some patients who may benefit from such therapy. Given the current uncertainty about the benefits and harms of extended DAPT therapy beyond one year, further elucidation of the controlled clinical trial data through a comprehensive overview of the evidence is required to inform health care decision-makers, policy-makers, clinicians, and patients.
In order to summarize the clinical benefits and harms associated with extending DAPT beyond 12 months, we performed a systematic overview (umbrella review) of previously published systematic reviews that have assessed the benefits and harms associated with extended DAPT. Of note, CADTH published a Health Technology Assessment report on the use of antiplatelet agents in patients undergoing PCI in June 2010 (www.cadth.ca/clopidogrel-versus-other-antiplatelet-agents-secondary-prevention-vascularevents-adults-undergoing). As such, this new report in part updates information from the 2010 report.
Objectives of the Report
The objective of this overview is to systematically review and summarize the evidence of the benefits and harms associated with extended DAPT following PCI with stenting.
