Abbreviated DAPT Cuts Bleeding Without Raising Ischemic Risk in High-Risk PCI

For patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI), shortening dual antiplatelet therapy (DAPT) to 1 or 3 months was associated with lower bleeding rates without a statistically significant increase in ischemic events overall compared with standard 6- to 12-month regimens, according to a systematic review and meta-analysis published in JAMA Cardiology.¹

“To our knowledge, this pairwise and network meta-analysis encompassing 11,398 patients at HBR from 14 RCTs [randomized controlled trials] represents the largest and most comprehensive evidence assessing the safety and efficacy of different DAPT durations in the HBR population,” wrote the researchers of the study.

DAPT, which combines aspirin with a P2Y12 inhibitor, remains the standard approach for preventing recurrent thrombotic events after PCI, but its ischemic benefits come at the cost of increased bleeding risk. Because the risk of ischemic events is generally highest in the first few months after stenting and then declines, while bleeding risk remains relatively constant over time, investigators have increasingly explored whether shorter DAPT courses can preserve cardiovascular protection while reducing bleeding complications, particularly in patients with HBR who face elevated risks on both fronts.

The analysis pooled data from 14 randomized clinical trials encompassing 11,398 patients with HBR (mean age, 74.7 years; 39.1% female) to further evaluate the optimal DAPT duration in this population. HBR status was defined using the PRECISE-DAPT score or Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria, and studies involving patients receiving oral anticoagulation were excluded.

Abbreviated DAPT Linked to Lower Bleeding Risk

Compared with standard DAPT, abbreviated regimens were associated with significantly lower rates of major or clinically relevant nonmajor bleeding (risk ratio [RR], 0.71; 95% CI, 0.55-0.92; P = .009) and major bleeding (RR, 0.76; 95% CI, 0.59-0.99; P = .04). Rates of major adverse cardiovascular events (MACE)—a composite of cardiovascular death, myocardial infarction, or stroke—did not differ significantly between groups (RR, 0.97; 95% CI, 0.81-1.16; P = .76), nor did any individual ischemic component, including stent thrombosis.

These findings remained consistent across multiple sensitivity analyses, including a leave-one-out approach, restriction to trials with centrally adjudicated outcomes, and analyses limited to trials using 12-month DAPT as the comparator.

A network meta-analysis comparing 1-month, 3-month, and standard DAPT found that both abbreviated durations lowered bleeding relative to standard therapy, with no significant differences in ischemic outcomes. However, in the single trial directly comparing 1-month with 3-month DAPT—the HOST-BR trial (NCT05631769)—1-month therapy was associated with a higher risk of MACE (RR, 1.58; 95% CI, 1.04-2.39), driven largely by ischemic stroke and cardiovascular death.² The pooled network estimate attenuated this finding to a nonsignificant trend (RR, 1.28; 95% CI, 0.95-1.72).¹ The study authors cautioned that the HOST-BR findings should be interpreted carefully given the limited number of direct comparisons between abbreviated regimens.

Notably, most direct evidence supporting 1-month DAPT came from ticagrelor-based trials, whereas the HOST-BR trial—which drove the ischemic signal against 1-month therapy—used clopidogrel in approximately 90% of patients, a distinction the authors said complicates direct comparisons across regimens.

The investigators also noted limitations including inconsistent bleeding definitions across trials, wide confidence intervals for some ischemic end points, and the exclusion of patients with certain high-risk features, such as prior intracranial bleeding, from many included studies. In addition, post-DAPT antiplatelet strategies varied across the included trials, with some studies transitioning patients to P2Y12 inhibitor monotherapy and others to aspirin monotherapy.

Managed Care Implications

These findings may provide additional support for health systems and payers considering abbreviated DAPT strategies in appropriately selected patients who meet HBR criteria, including a PRECISE-DAPT score of at least 25 or ARC-HBR criteria. Because bleeding complications can lead to costly downstream consequences, including hospitalization and transfusion, abbreviated DAPT strategies may have the potential to reduce the total cost of care, although cost-effectiveness was not evaluated in this analysis.

The findings also suggest that clinicians may exercise greater caution when selecting 1-month regimens until additional comparative data become available. Care management programs may therefore benefit from considering both antiplatelet agent selection and treatment duration when developing pathways for patients with HBR following PCI.

“Emerging technologies and novel agents may further shift the paradigm of antithrombotic therapy in patients at HBR,” wrote the researchers. “These include biodegradable polymer stents, drug-coated balloons, or alternative antithrombotic agents with more favorable bleeding profiles. Ongoing trials will be instrumental in integrating these innovations into practical and patient-centered strategies.”

References

1. Zito A, Landi A, Bhatt DL, et al. Dual antiplatelet therapy duration in patients at high bleeding risk: a systematic review and meta-analysis. JAMA Cardiol. Published online June 24, 2026. doi:10.1001/jamacardio.2026.1922
2. Kang J, Park KW, Han JK, et al. Dual antiplatelet therapy after percutaneous coronary intervention according to bleeding risk (HOST-BR): an open-label, multicenter, randomized clinical trial. Lancet. 2025;406(10516):2244-2256. doi: 10.1016/S0140-6736(25)01571-5