Contemporary improvements in stent design and more potent P2Y12 inhibitors have changed the trade-off between ischemic protection and bleeding after percutaneous coronary intervention. Historically, 12 months or longer of dual antiplatelet therapy (DAPT) was standard to reduce stent thrombosis and recurrent ischemic events, but prolonged therapy increases bleeding risk. Randomized trials conducted since 2008 have tested abbreviated DAPT durations, including 1-month and 3-month regimens, aiming to reduce bleeding while preserving ischemic protection. Clinical guidelines from ACC/AHA and ESC have incorporated shorter regimens and early transition to P2Y12 monotherapy, but direct comparisons across multiple abbreviated durations remain limited. This network meta-analysis was undertaken to synthesize direct and indirect randomized evidence and to rank distinct DAPT durations after PCI with contemporary drug-eluting stents (DES).
This study was a systematic review and frequentist network meta-analysis prospectively registered on PROSPERO (CRD420261349664) and reported according to PRISMA guidance. The authors searched PubMed, Embase, and Scopus for randomized controlled trials published from January 2008 through March 21, 2026 to reflect the contemporary era of second- and third-generation DES. Eligible studies were parallel-group RCTs in adults (≥18 years) undergoing PCI with contemporary DES that compared at least two distinct DAPT durations and reported clinical outcomes. Trials primarily enrolling patients with atrial fibrillation who required oral anticoagulation were excluded.
Primary outcomes were trial-defined major adverse cardiovascular events (MACE) for efficacy and major bleeding for safety. Two reviewers independently screened studies and extracted data; risk of bias was appraised using the Cochrane RoB2 tool. The certainty of evidence was assessed using GRADE.
A multivariate random-effects network meta-analysis was performed in Stata using restricted maximum likelihood estimation. Relative treatment effects are reported as risk ratios (RR) with 95% confidence intervals (CI). Consistency between direct and indirect evidence was evaluated with global chi-squared tests and local node-splitting analyses. Treatment rankings were estimated using SUCRA values. Publication bias was assessed via comparison-adjusted funnel plots and a network-wide adaptation of Egger’s test.
From 2,684 identified records, 28 randomized trials enrolling a total of 84,325 patients met inclusion criteria. The analysis compared abbreviated DAPT strategies (including 1-, 3-, and 6-month regimens) against the conventional 12-month DAPT reference and other durations where available.
Efficacy (MACE): Compared with 12-month DAPT, the abbreviated strategies did not show a statistically significant difference in MACE: 1-month DAPT RR 1.03 (95% CI 0.88–1.22); 3-month DAPT RR 0.95 (95% CI 0.82–1.10); 6-month DAPT RR 1.06 (95% CI 0.88–1.27). Thus, no abbreviated duration demonstrated a clear ischemic disadvantage relative to 12 months in the pooled randomized evidence.
Safety (major bleeding): Abbreviated DAPT durations were associated with lower major bleeding compared with 12 months. The 1-month strategy showed the largest reduction (RR 0.59, 95% CI 0.42–0.82). The 3-month strategy also reduced major bleeding (RR 0.64, 95% CI 0.49–0.84). The 6-month strategy exhibited a consistent trend toward reduced bleeding (RR 0.68, 95% CI 0.46–1.00).
Treatment ranking (SUCRA): SUCRA values suggested that the 3-month DAPT strategy ranked highest for the lowest ischemic risk (MACE), whereas the 1-month DAPT strategy ranked highest for lowest bleeding risk. Across analyses, the 3-month regimen demonstrated the most favorable overall profile when balancing ischemic and bleeding outcomes.
Additional analyses: The report describes assessment of inconsistency, publication bias, and GRADE-based certainty ratings; specific domain-level judgments and trial-level characteristics are presented in the full manuscript and supporting files.
In this aggregated randomized evidence set focused on PCI with contemporary DES, abbreviated DAPT strategies of 1 and 3 months were associated with reduced major bleeding and did not demonstrate an increased risk of MACE compared with conventional 12-month therapy. The network meta-analysis framework allowed indirect comparisons and ranking across multiple abbreviated durations, indicating that a 3-month threshold may offer a pragmatic balance between ischemic protection and bleeding avoidance.
However, the absence of statistically significant differences in efficacy endpoints between abbreviated and 12-month regimens mandates cautious interpretation. Individual trials were often underpowered for infrequent ischemic events, and differences in trial definitions and patient mixes may influence pooled estimates. The authors emphasize that trial-level network meta-analysis cannot substitute for patient-level randomized comparisons in all subgroups, and residual confounding across trials may persist despite methodological safeguards.
Strengths of the analysis include a pre-registered protocol, comprehensive searches limited to the contemporary DES era (2008 onward), inclusion of only randomized trials, standardized extraction and risk-of-bias assessment, and use of network meta-analysis methods to compare multiple DAPT durations simultaneously. Limitations noted by the authors include reliance on study-level data, heterogeneity in endpoint definitions and trial populations, potential for inconsistency or small-study effects despite formal testing, and the inability to derive individualized recommendations for specific high-risk subgroups from aggregated data.
Among RCTs of PCI with contemporary DES, abbreviated DAPT regimens of 1 and 3 months reduced major bleeding compared with 12-month therapy without evidence of increased ischemic events. The 3-month strategy consistently demonstrated the most favorable overall profile across analyses and may represent a pragmatic threshold for DAPT abbreviation. These findings should be interpreted with caution due to limitations inherent to study-level network meta-analysis and the lack of definitive efficacy differences; individualized clinical judgment and guideline recommendations remain essential.