Early Discontinuation of Aspirin Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention with a Drug-Eluting Stent: A Meta-Analysis

KEY POINTS: P2Y12 inhibitor monotherapy after 1–3 months of dual antiplatelet therapy (DAPT) decreases the risk of clinically significant bleeding when compared with 12 months of DAPT in patients with CKD treated with a drug-eluting stent. There is no significant difference in the risk of cardiovascular events with early aspirin discontinuation when compared with 12 months of DAPT post-PCI in patients with CKD. BACKGROUND: Conflicting evidence exists to support whether short duration of dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduces bleeding complications after coronary artery drug-eluting stent (DES) insertion, compared with standard 12-month DAPT, particularly among patients with CKD who are at increased risk of bleeding. METHODS: A MEDLINE search identified randomized trials comparing up to 3 months of DAPT followed by P2Y12 inhibitor monotherapy versus twelve months of DAPT after insertion of a DES for any indication. Trials were included if they reported ischemic or bleeding outcomes among patients with CKD. The primary outcome was a composite of all-cause mortality, cardiac or cerebrovascular events, stent thrombosis (MACE), and major or minor bleeding events. Secondary outcomes were the individual components of the primary outcome and clinically significant bleeding. The relative risk (RR) was estimated using a random-effects model. RESULTS: Seven randomized trials were included for a total of 4996 patients with CKD (14% of the trial population). Early discontinuation of aspirin was associated with a similar incidence of the primary outcome among patients with CKD compared with 12-month DAPT (RR 0.97; 95% confidence interval [95% CI] 0.73 to 1.30). The RR of MACE was also similar between the two arms (RR 1.02; 95% CI 0.85 to 1.23). The risk of clinically significant bleeding was significantly lower with early discontinuation of aspirin (RR 0.60; 95% CI 0.46 to 0.78). CONCLUSION: P2Y12 inhibitor monotherapy after a shortened course of DAPT seems to be associated with a similar risk of ischemic events and a lower risk of bleeding events after DES insertion among patients with CKD compared with 12-month DAPT.