Meta-Analyses on DAPT Length: Chasing the Calm After the (Perfect) Storm

In the last 2 years clinicians were all caught in the middle of a perfect storm of meta-analyses regarding dual antiplatelet therapy (DAPT). Recently, Palmerini et al. reaffirmed the link between bleeding, all cause mortality, and DAPT duration after drug eluting stent implantation. The storm started with a meta-analysis by the same author showing a mortality increase in patients treated with longer DAPT regimen. Two worthy studies seemed to brighten up the sky for clinicians. Yeh et al. suggested that the myocardial infarction (MI) asclinical presentation could be the discriminating factor in DAPT decision-making. Patients presenting with MI showed a benefit from longer DAPT in terms of recurrence of MI, without any increase in mortality. Similarly, the collaborative metaanalysis of randomized trials on patients with MI by Udell et al. confirmed the paramount importance of clinical presentation, showing a cardiovascular mortality reduction without increase of noncardiovascular mortality and fatal bleedings in patients treated with longer DAPT regimen. Then, clinicians are likely to refall into confusion reading the present meta-analysis in which post-MI patients are only 14%. As a matter of fact, the same metaanalysis starting the storm included a small portion of prior-MI (19%) and index-MI (25%) patients. We think that, to reach the “calm after the storm,” clinicians should stop stressing old studies with old P2Y12 inhibitors on stable patients and address the real unmet clinical need in everyday clinical practice, namely the recurrence of ischemic adverse events in post-MI patients.