Efficacy and safety of dual antiplatelet therapy de-escalation in East Asian individuals following percutaneous coronary intervention for acute coronary syndrome: a systematic review and meta-analysis

East Asian patients with acute coronary syndrome (ACS) are more prone to bleeding complications than Western populations under comparable antithrombotic regimens. This pattern presents a considerable obstacle to the routine use of intensive dual antiplatelet therapy (DAPT) undergoing percutaneous coronary intervention (PCI). Consequently, the effectiveness and safety of DAPT de-escalation strategies tailored to this particular group of patients remain inadequately defined. An extensive search of both Chinese and English literature databases was performed up to June 2025 to locate cohort studies and randomized controlled trials assessing the effectiveness and safety of de-escalating DAPT in East Asian individuals diagnosed with ACS. The primary outcomes included major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke, and bleeding outcomes, with bleeding classified according to Bleeding Academic Research Consortium (BARC) criteria. Meta-analytical methods were applied using either fixed-effects or random-effects models, depending on data suitability. A total of nine studies were included in the analysis, consisting of five RCTs and four cohort studies, encompassing 10,263 patients overall. Compared to standard DAPT, the de-escalation approach was significantly linked to lower risks of BARC type 1 bleeding (RR = 0.52; 95% CI: 0.32–0.86; p = 0.011), BARC type ≥ 2 bleeding (RR = 0.47; 95% CI: 0.37–0.60; p < 0.001), and BARC type ≥ 3 events (RR = 0.61; 95% CI: 0.40–0.94; p = 0.026). Nonetheless, the comparison between de-escalation and standard regimens revealed no statistically meaningful difference in MACE risk (RR = 0.91; 95% CI: 0.70–1.19; p = 0.497). This result remained stable across the separate elements comprising the MACE composite outcome. Among East Asian patients with ACS, implementing a DAPT de-escalation strategy lowers bleeding risk without elevating ischemic events, suggesting a potentially favorable safety profile in East Asian patients. Further validation by RCTs is warranted.