Aims Dual-antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 inhibitor is
the standard treatment for patients with acute coronary syndrome (ACS) undergoing
percutaneous coronary intervention (PCI). De-escalation of the potent P2Y12 inhibtor
is an appealing concept to balance the ischaemic and bleeding risks after PCI. An
individual patient data meta-analysis was performed to compare de-escalation versus
standard DAPT in patients with ACS. Methods and results Electronic databases, including
PubMed, Embase, and the Cochrane database, were searched to identify randomised clinical
trials (RCTs) comparing the de-escalation strategy with the standard DAPT after PCI
in patients with ACS. Individual patient-level data were collected from the relevant
trials. The co-primary endpoints of interest were the ischaemic composite endpoint
(a composite of cardiac death, myocardial infarction, and cerebrovascular events)
and bleeding endpoint (any bleeding) at 1-year post-PCI. Four RCTs (the TROPICAL-ACS,
POPular Genetics, HOST-REDUCE-POLYTECH-ACS, and TALOS-AMI trials) including 10 133
patients were analysed. The ischaemic endpoint was significantly lower in the patients
assigned to the de-escalation strategy than in those assigned to the standard strategy
(2.3% vs. 3.0%, hazard ratio [HR] 0.761, 95% confidence interval [CI] 0.597-0.972,
log rank P = 0.029). Bleeding was also significantly lower in the de-escalation strategy
group (6.5% vs. 9.1%, HR 0.701, 95% CI 0.606-0.811, log rank P < 0.001). No significant
intergroup differences were observed in terms of all-cause death and major bleeding
events. Subgroup analyses revealed that compared to guided de-escalation, unguided
de-escalation had a significantly larger impact on bleeding endpoint reduction (P
for interaction = 0.007); no intergroup differences were observed for the ischaemic
endpoints. Conclusion In this individual patient data meta-analysis, DAPT-based de-escalation
was associated with both decreased ischaemic and bleeding endpoints. Reduction in
bleeding endpoints was more prominent for the unguided than the guided de-escalation
strategy. Study registration number This study was registered in the PROSPERO (ID:
CRD42021245477).
