Duration of dual antiplatelet therapy and risk of stent thrombosis in patients undergoing complex PCI: a meta-analysis

BACKGROUND: Patients undergoing complex percutaneous coronary intervention (PCI) have a higher risk of ischemic events and often receive extended dual antiplatelet therapy (DAPT), particularly to protect against stent thrombosis (ST). The selection of an optimal DAPT strategy in this setting remains challenging given the intrinsic ischemic and bleeding risk. Previous observations have not clearly established the impact of non-standard DAPT duration regimens on ischemic events in complex PCI patients. This study aims to assess the effect of non-standard DAPT duration on ischemic events in this setting. METHODS AND RESULTS: We searched for randomized trials comparing DAPT duration regimens in patients undergoing complex PCI. The primary outcome was definite/probable ST. Other outcomes were myocardial infarction (MI), all-cause death, and major bleeding. Seven trials with a total of 46,696 patients undergoing either complex (n = 13,469) or non-complex (n = 33,227) PCI were included in the analysis. In complex PCI patients, the risk of definite/probable ST was not significantly different between the non-standard DAPT and standard DAPT groups (incidence rate ratio (IRR) 1.08; 95% confidence intervals (CI) 0.63-1.82). Consistently, the risk of MI (IRR 0.87; 95% CI 0.70-1.09), all-cause death (IRR 0.85; 95% CI 0.51-1.39), and major bleeding (IRR 0.63; 95% CI 0.33-1.19) did not differ significantly between DAPT strategies. Treatment effect for definite/probable ST by DAPT duration strategy was independent of PCI complexity. CONCLUSIONS: In patients undergoing complex PCI, we found no significant differences in stent thrombosis, myocardial infarction, all-cause death, and major bleeding between DAPT duration strategies. PROSPERO REGISTRATION NUMBER: CRD42024617534.