Sex-related outcomes in patients receiving shortened or longer dual antiplatelet treatment after percutaneous coronary intervention: a systematic review and meta-analysis

Abstract Background There are known gender disparities in the pathophysiology, clinical presentation, and prognosis of coronary artery disease between male and female patients. Although antiplatelet therapy cessation is more frequent among women, female gender is an independent factor for major bleeding after percutaneous coronary interventions. Considering that the ischemic and bleeding risk of women undergoing PCI differ from men, it follows that the safety and efficacy of shortened, one or 3 months, DAPT (S-DAPT) compared to longer DAPT (L-DAPT) after PCI might differ between the sexes. Purpose Our systematic review and meta-analysis aims to explore the safety and efficacy of S-DAPT versus L-DAPT in men and women having undergone PCI. Methods Three major databases (MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were screened for eligible randomized – controlled trials, or subgroup or post – hoc analyses of them. The studies should compare S-DAPT with L-DAPT in male and female patients undergoing PCI, providing separate data. The endpoints were Net Adverse Clinical Events (NACE), Major Adverse Cardiac Events (MACE), all-cause mortality, myocardial infarction and major bleeding. All endpoints were used as per trial defined and should be evaluated in 12-months. The effect of different DAPT regimens was assessed by calculating the risk ratio (RR) with 95% confidence intervals (CIs), using a random-effects model (Mantel-Haenzel). Results A total of eight studies and 46,476 patients were included; women were underrepresented being only the 26% (N=12,063) of the total participants. MACE did not differ significantly in the two arms in the total sample (RR: 0.94, 95%CI: 0.86-1.04); however, they were significantly reduced in women treated with S-DAPT (RR: 0.82, 95%CI: 0.70-0.97) (p-interaction: 0.049). (Figure 1) S-DAPT was associated with a significant reduction in both NACE (RR: 0.91, 95% CI: 0.85-0.99) (Figure 2A) and major bleeding (RR: 0.73, 95% CI: 0.57-0.95) (Figure 2C) in the total sample, without significant differences between male and female patients (p-interaction: 0.14 and 0.053, respectively). All-cause mortality (RR: 0.86, 95%CI: 0.73-1.01) (Figure 2B) and myocardial infarction rates (RR: 1.03, 95%CI: 0.86-1.24) (Figure 2D) were similar in both S-DAPT and L-DAPT in the total sample, without any significant subgroup differences (p-interaction: 0.13 and 0.051, respectively). Conclusions Shortened duration of DAPT significantly decreased MACE in women, in contrast with male patients, showing that women may benefit from abbreviated duration of DAPT. Further studies specifically investigating the optimal duration of DAPT in women are warranted and a sex-based approach could be considered in the management of antiplatelet treatment after PCI.A. NACE B. Mortality C. Bleedings D. MI