What is the most effective DAPT strategy for acute coronary syndrome treatment?

De-escalation of dual antiplatelet therapy (DAPT) is the most effective approach for the treatment of acute coronary syndrome (ACS), which leads to fewer bleeding events without increasing ischaemic events, compared with other established uses of DAPT, reveals a recent study.

The investigators sought to compare the efficacy and safety outcomes of various DAPT strategies in ACS patients, including de-escalation from a potent P2Y₁₂ inhibitor to clopidogrel or low-dose prasugrel. They searched Medline and Embase through January 2021 for randomized controlled trials (RCTs) examining the efficacy and safety of DAPT in ACS patients and conducted a network meta-analysis.

A composite of cardiovascular death, myocardial infarction, and stroke was the primary efficacy outcome. The primary bleeding outcome was defined as either major or minor bleeding.

Fifteen RCTs, including a total of 55,798 patients with ACS, met the eligibility criteria. De-escalation therapy resulted in a reduced risk of primary bleeding outcomes (hazard ratio [HR] vs clopidogrel, 0.48, 95 percent confidence interval [CI], 0.30–0.77; HR vs ticagrelor, 0.32, 95 percent CI, 0.20–0.52; HR vs standard-dose prasugrel, 0.36, 95 percent CI, 0.24–0.55; HR vs low-dose prasugrel, 0.40, 95 percent CI, 0.22–0.75), with no negative effects on primary efficacy outcomes.

No significant differences were observed in ischaemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel.

“Balancing the effects of DAPT in the era of potent P2Y₁₂ inhibitors has become a cornerstone of ACS management,” the investigators said. “Recent RCTs have investigated DAPT de-escalation to decrease the risk of bleeding outcomes.”