What is the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention in high-bleeding risk: 1 month or 3 months?

This commentary refers to ‘Dual antiplatelet therapy duration after percutaneous coronary intervention in high-bleeding risk: a meta-analysis of randomized trials’, by F. Costa et al., https://doi.org/10.1093/eurheartj/ehac706 and the discussion piece ‘One or 3 months dual antiplatelet therapy in high-bleeding risk patients: splitting hair or aiming at the bullseye’, by F. Costa et al., https://doi.org/10.1093/eurheartj/ehad729. Dual antiplatelet therapy (DAPT) is the cornerstone of secondary prevention in patients following percutaneous coronary intervention (PCI). The duration of DAPT has been one of the major questions in recent years, especially for patients with high bleeding risk (HBR). The 2017 European Society of Cardiology (ESC) recommends 3 and 6 months of DAPT after PCI for patients with stable coronary artery disease and acute coronary syndrome at HBR, respectively.1 However, the latest guidelines from ESC recommend 3 months of DAPT after PCI for both chronic coronary syndrome patients with a higher risk of life-threatening bleeding2 and non-ST-segment elevation acute coronary syndrome (ACS) patients with HBR.3 To date, the duration of DAPT after PCI in patients with HBR seems to be becoming unified. We read with great interest the report of the recent meta-analysis by Costa et al., which shows that a 1- or 3-month abbreviated DAPT was associated with lower bleeding, without increasing ischaemic events, compared with a standard DAPT regimen in patients with HBR undergoing PCI.4 The results of this study are consistent with recommendations from the current guidelines. Based on this meta-analysis, we think what readers are truly interested in and concerned about is whether 1 month or 3 months of DAPT is better. It is interesting to see that in addition to the STOPDAPT-2-ACS trial,5 the abbreviated duration was 1 month in 4 trials and 3 months in 6 trials. Thus, it is suggested that the authors perform a subgroup analysis to provide the clinic with a more accurate abbreviated DAPT duration. All authors declare no disclosure of interest for this contribution.