Risk–Benefit Profile of Oral Antiplatelet Strategies After Percutaneous Coronary Intervention with a Drug-eluting Stent: A Contemporary Network Meta-analysis of Major Bleeding and Stent Thrombosis Outcomes

Abstract

Optimal antiplatelet therapy after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) requires balancing thrombotic protection and bleeding risk, but the comparative effectiveness of current strategies remains uncertain. Aims: To evaluate the risk–benefit profile of oral antiplatelet strategies after PCI with DES, focusing on major bleeding and stent thrombosis. Methods: A network meta-analysis of randomised and observational studies was conducted. Strategies included standard or extended dual antiplatelet therapy (DAPT), shortened DAPT followed by monotherapy and P2Y12 inhibitor-based monotherapy. Outcomes were analysed using a random-effects model and ranked with p-scores. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results: Thirty studies involving 110,035 patients were included. Ticagrelor monotherapy ranked highest for reducing major bleeding, whereas extended DAPT provided the greatest protection against stent thrombosis, with clopidogrel-based therapy beyond 12 months ranking highest (RR 0.08; 95% CI [0.01–0.52]; p-score=0.94). Notably, clopidogrel monotherapy after prolonged DAPT demonstrated a relatively balanced profile across both outcomes. However, no strategy was consistently optimal and most estimates showed wide CIs. Conclusion: Antiplatelet strategies after PCI with DES involve a clear trade-off between bleeding and thrombotic risk. Clopidogrel monotherapy after prolonged DAPT may offer a balanced approach, although findings should be interpreted cautiously due to limited precision and consistency.