Recurrent Events Analysis of MASTER DAPT: Total Ischemic and Bleeding Events After Abbreviated vs Prolonged DAPT in HBR Patients (JACC August 2025-1)-Article: Recurrent Events Analysis of MASTER DAPT: Total Ischemic and Bleeding Events After Abbreviated vs Prolonged DAPT in HBR Patients

Article: Recurrent Events Analysis of MASTER DAPT: Total Ischemic and Bleeding Events After Abbreviated vs Prolonged DAPT in HBR Patients

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The MASTER DAPT trial examined the impact of abbreviated (median 34 days) versus prolonged (median 192 days) dual antiplatelet therapy (DAPT) in 4,579 patients at high bleeding risk (HBR) following percutaneous coronary intervention (PCI) with bioresorbable polymer-coated sirolimus-eluting stents. This study specifically evaluated total ischemic and bleeding events, including recurrent events, over 11 months post-randomization, unlike typical analyses which consider only the first event.<br /><br />Key findings showed that abbreviated DAPT yielded similar rates of net adverse clinical events (NACEs, composite of death, myocardial infarction [MI], stroke, or major bleeding) and major adverse cardiac and cerebral events (MACCEs, composite of death, MI, or stroke) compared to prolonged DAPT. Importantly, abbreviated DAPT was associated with significantly fewer total major or clinically relevant nonmajor bleeding events (MCB, BARC types 2, 3, or 5), with a number needed to treat (NNT) of 38 to prevent one MCB event at 11 months.<br /><br />Patients on abbreviated DAPT experienced notably fewer total cerebrovascular accidents (CVAs) and strokes, with hazard ratios near 0.5, suggesting nearly half the risk compared to prolonged DAPT. Recurrent bleeding after minor BARC type 1 events was halved in the abbreviated group, indicating a benefit in reducing bleeding recurrence. The time from first to second MI was also longer on abbreviated DAPT, though total MI and stent thrombosis rates were similar between groups. Approximately 20% of MACCEs occurred following bleeding events, emphasizing bleeding as a sentinel event that may predispose to ischemic complications.<br /><br />The open-label design allowed observation of therapy adaptations after events; patients with bleeding often had antithrombotic therapy downgraded, particularly in the prolonged DAPT group, which may have influenced recurrent bleeding rates. The study supports initial use of abbreviated DAPT in HBR patients to minimize bleeding without increasing ischemic risk. It highlights the clinical importance of considering total and recurrent events for comprehensive assessment and individualized DAPT duration strategies after PCI. Limitations include open-label treatment, patient selection excluding early ischemic events, and use limited to a specific stent type. Overall, the findings reinforce guidelines favoring shorter DAPT in HBR patients and suggest immediate DAPT discontinuation upon bleeding events after the first month.

Keywords

MASTER DAPT trial

dual antiplatelet therapy

abbreviated DAPT

prolonged DAPT

high bleeding risk

percutaneous coronary intervention

bioresorbable polymer-coated sirolimus-eluting stents

net adverse clinical events

major bleeding events

recurrent ischemic events