RapidMeta Cardiology | DAPT De-Escalation Post-PCI Ultra-Precision v12.0

Systematic Review Protocol

PROSPERO-style Registration — PRISMA 2020 & AMSTAR 2 Compliant

1. Registration & Administrative Information [PRISMA #24, AMSTAR #2]

Review Title	Short-Duration DAPT followed by P2Y12 or Aspirin Monotherapy after PCI: A Living Network Meta-Analysis of Randomized Controlled Trials
Protocol Version	v1.0 (Living Protocol — auto-updating)
Date of First Registration	2026-03-03
Last Substantive Amendment	2026-03-03
Planned Update Frequency	Continuous (living review); formal snapshot at each new trial publication
Funding Source	No external funding (independent academic review)
Conflicts of Interest	None declared
Contributor Roles (CRediT)	MA — Conceptualization, Methodology, Data Curation, Writing (Original Draft & Review & Editing), Supervision. Per ICMJE 2023: human author takes full responsibility for accuracy and integrity of the work, including all AI-assisted components.
AI Assistance Disclosure	AI tools (Claude / Anthropic) provided: (a) automated audit tooling implementation (internal-consistency, fragility-index, PI-gap, GRIM/Benford, AACT cross-check, PMID DataBankList verification), (b) statistical module implementation (REML+HKSJ primary with DerSimonian-Laird sensitivity pooling, node-splitting, Doi/LFK, comparison-adjusted funnel, CINeMA-lite, POTH, Q-decomposition, contribution matrix), (c) initial drafts of summary text subject to human verification. AI is NOT listed as an author per ICMJE 2023; AI cannot take responsibility for a manuscript. All AI-generated content was reviewed and verified by the human author. The audit/extraction infrastructure is open-source at the GitHub repository for independent verification.

2. Review Question — PICO Framework [PRISMA #3, AMSTAR #1]

Population
Intervention
Comparator
Primary Outcome
Secondary Outcomes	All-cause mortality; HF hospitalization; urgent HF visits; renal composite where reported
Subgroup Plan

3. Eligibility Criteria [PRISMA #5–6, AMSTAR #3]

Criterion	Inclusion	Exclusion
Study Design	Randomized controlled trials (RCTs), parallel or crossover	Non-randomized, observational, single-arm, case series
Phase	Phase III or IV	Phase I/II (including IIa/IIb), PK/PD, dose-finding, bioequivalence, first-in-human
Participants	Adults with HF	Healthy volunteers, paediatric, animal/in-vitro
Intervention	Ticagrelor mono after 3mo DAPT and related agents	SGLT2i as background only; open-label extensions without comparator
Comparator	Placebo, sham, or standard of care	Active comparator without placebo arm
Outcomes	≥1 heart-failure clinical endpoint with extractable 2×2 counts or published HR/RR with confidence interval	Biomarker-only, PK-only, no clinical event data
Publication	Published or registered; any language	Pre-2015; duplicate cohorts; editorials, letters, reviews
Follow-up	≥12 weeks (primary outcome assessment)	<12 weeks or acute/single-dose studies

4. Information Sources & Search Strategy [PRISMA #7–8, AMSTAR #4–5]

Database	Search String / API Query	Type
ClinicalTrials.gov	`https://clinicaltrials.gov/api/v2/studies?query.term=heart%20failure%20sglt2&pageSize=100&filter.overallStatus=COMPLETED`	Registry (API v2)
PubMed (Europe PMC)	`(Ticagrelor mono after 3mo DAPT OR Clopidogrel mono after 1mo DAPT OR P2Y12 mono after 3mo DAPT OR Ticagrelor mono after 1mo DAPT OR 1mo DAPT in HBR patients) AND "DAPT De-Escalation Post-PCI" AND (randomized OR "randomized controlled trial")"heart failure" AND (TITLE:randomized OR PUB_TYPE:"Randomized Controlled Trial" OR PUB_TYPE:"Clinical Trial") AND SRC:MED`	Bibliographic (REST)
OpenAlex	`search=sglt2%20heart%20failure&per_page=50`	Bibliographic (REST)
Reference Check	Backward citation search: built-in landmark database cross-checked against API returns	Manual supplement

Deduplication [PRISMA #16a]

NCT-ID exact match → PubMed dbCrossReferenceList linkage → NCT pattern extraction from abstract → fuzzy title dedup (normalized alphanumeric). Enrichment: abstracts, authors, journal metadata merged from PubMed into registry stubs. All 3 fetches run in parallel via Promise.allSettled.

5. Study Selection Process [PRISMA #16, AMSTAR #5–7]

Stage 1: Auto-Screening	RCT relevance classifier (keyword + publication type scoring, 0–100). Auto-exclude <25. App location: Screening tab
Stage 2: Title/Abstract	Two-reviewer adjudication workflow with rationale note and second-review confirmation (I = propose include, E = propose exclude, C = second confirmation, N/P = navigate). App location: Screening tab
Stage 3: Full Text	Verify eligibility criteria against full manuscript; extract 2×2 table. App location: Extraction tab
Conflict Resolution	Re-review with exclusion reason recorded in audit log. PRISMA flow auto-generated.
PRISMA Flow Diagram	Auto-computed from search/screening counts. App location: Report tab → PRISMA section

6. Data Collection & Extraction [PRISMA #10, AMSTAR #6]

Data Item	Details	App Location
Study identifiers	NCT ID, PMID, DOI, first author, year	Extraction → Data Entry
Participants	N randomized per arm, age, sex distribution, indication, baseline eGFR	Extraction → Demographics
Intervention details	Intervention dose/regimen, trial phase, treatment duration	Extraction → Data Entry
Outcome events	2×2 table: Events(Tx), N(Tx), Events(Ctrl), N(Ctrl); or published HR/RR with confidence interval for recurrent/time-to-event estimands	Extraction → Data Entry
Risk of Bias	RoB 2 domains D1–D5, each rated Low/Some/High	Extraction → Risk of Bias
Source evidence	Verbatim extracts from published manuscripts with page/table references	Extraction → Evidence panels

7. Risk of Bias Assessment [PRISMA #11–12, AMSTAR #9]

Domain	Signalling Questions (RoB 2)	App Location
D1: Randomization	Sequence generation, allocation concealment	Extraction → RoB (click to cycle)
D2: Deviations	Blinding, ITT adherence, co-interventions	Extraction → RoB (click to cycle)
D3: Missing Data	Completeness, attrition handling, sensitivity for missing	Extraction → RoB (click to cycle)
D4: Measurement	Outcome assessment blinding, adjudication committees	Extraction → RoB (click to cycle)
D5: Selective Reporting	Pre-registered endpoints, protocol deviations	Extraction → RoB (click to cycle)
Presentation	Traffic-light summary table (per-study) + stacked horizontal bar chart (per-domain)	Analysis → Charts #16, Extraction → RoB

8. Synthesis & Statistical Methods [PRISMA #13, AMSTAR #11–12]

Method	Specification	App Location
Effect Measure	Odds Ratio (OR) computed on log scale; 0.5 continuity correction for zero cells	Analysis → Stats
Pooling Model	REML random-effects, HKSJ-adjusted (inverse-variance weighting)	Analysis → Forest (#1)
CI Adjustment	Hartung-Knapp-Sidik-Jonkman (HKSJ); t-distribution with df = k−1	Analysis → Stats
Prediction Interval	t-distribution, df = k−1 (Cochrane Handbook v6.5)	Analysis → Stats
Heterogeneity	Cochran Q (p-value), I² (%), τ² (DL estimator)	Analysis → Stats
Subgroup Analysis	By HF phenotype (HFrEF vs HFpEF/HFmrEF); Q-between test for interaction	Analysis → Subgroup (#2)
Cumulative MA	Sequential addition by year; monitoring evidence accrual	Analysis → Cumulative (#3)
Leave-One-Out	Influence analysis: remove each study, re-pool	Analysis → LOO (#5)
Bayesian RE	Grid approximation (200 τ × 300 μ); half-normal prior on τ; posterior OR + CrI + P(OR<1)	Analysis → Posterior (#11)
Meta-Regression	WLS on log-OR; covariates: Year, Phase, Indication; Knapp-Hartung SE; permutation p (1000x)	Analysis → Meta-Reg (#12)
Fragility Index	Walsh method: sequential single-arm event modification until significance flips	Analysis → Stats
NNT / Clinical Utility	NNT = 1 / ARR; curve across baseline risk range	Analysis → NNT (#8)
HR Data Source	Published HRs cross-validated against ClinicalTrials.gov API v2 `resultsSection` structured data (Cox regression). All 5 trials have concordant HR values between NEJM publications and CT.gov registry. Renal composite HRs sourced exclusively from CT.gov.	Evidence → CT.gov API v2 Validation
HR Pooling (sensitivity)	Fixed-effect inverse-variance pooling of log(HR); SE derived from published 95% CI. Displayed in HR chip and HR/RR mode. Excludes recurrent-event estimands (SOLOIST-WHF) from HR pool.	Analysis → Stats

9. Publication Bias Assessment [PRISMA #14–15, AMSTAR #15]

Method	Specification	App Location
Visual	Contour-enhanced funnel plot with significance regions (p < 0.01/0.05/0.10)	Analysis → Funnel (#9)
Statistical	Egger's weighted regression test: intercept ≠ 0 (k ≥ 3 required)	Analysis → Egger (#15)
Correction	Duval-Tweedie trim-and-fill (L0 estimator); imputed studies shown as open circles on funnel	Analysis → Stats chip
Sensitivity	Copas-style sensitivity (heuristic rank-reweighting, not Copas-Shi MLE): ρ sweep −0.99 to 0 (34 steps); classify Robust/Sensitive	Analysis → Copas (#13)
Power	RIS formula with D² diversity; conditional power curve (next-study N 100–2000)	Analysis → Power (#14)

10. Certainty of Evidence [PRISMA #22, AMSTAR #14]

GRADE Domain	Criteria for Downgrading	App Location
Risk of Bias	≥50% studies rated Some Concerns or High on any domain	Report → GRADE
Inconsistency	I² ≥ 50% or prediction interval crosses null	Report → GRADE
Indirectness	Population, intervention, or outcome mismatch with review question	Report → GRADE
Imprecision	CI crosses MID (OR = 0.80 or 1.25) or optimal information size not met	Report → GRADE
Publication Bias	Egger p < 0.10, asymmetric funnel, Copas sensitivity, trim-fill k0 > 0	Report → GRADE
Supplementary	Bayesian P(OR < 1), Information Fraction (RIS), Summary of Findings table	Report → SoF table

10b. Safety Profile (Adverse Events) [PRISMA #20d]

Component	Description	App Location
Data Source	ClinicalTrials.gov API v2 `resultsSection.adverseEventsModule` for all 5 included trials. Provides MedDRA preferred terms with event counts per arm.	Analysis → Chart 19
Reporting Threshold	CT.gov only reports events exceeding the trial's reporting threshold (typically ≥5 events per arm). Events below threshold are noted but excluded from pooled rate calculations.	Chart 19 footnote
Pooling Method	Crude pooled rates: sum of events across trials / sum of arm-level denominators. Risk ratio (RR) with Wald-type CI from log-RR ± z×SE. Not inverse-variance weighted (events too sparse for proper MA).	Chart 19 table
AE Categories	Total serious AEs (SAE), plus SGLT2i-specific signals: UTI, Fournier's gangrene, DKA, genital mycotic infections, hypotension, dehydration, diarrhoea (SGLT1-mediated for sotagliflozin).	Chart 19 rows
Limitations	CT.gov primarily reports SAEs above a reporting threshold (≥5 events), so non-serious but clinically important AEs (e.g., genital mycotic infections, the most established SGLT2i class effect) are systematically undercounted or absent. Not all trials report all AE terms — rates use only denominators from trials reporting each term. Volume depletion/hypovolemia data is incomplete across trials. Total SAE data available from only 1 of 5 trials (DAPA-HF). SOLOIST-WHF (100% T2DM, dual SGLT1/2i) may inflate GI and metabolic AE rates when pooled with mixed-diabetes trials. Pooled rates are unadjusted (no covariate or exposure correction). Concordance with published safety meta-analyses (Vaduganathan et al., Lancet 2022) should be verified for clinical interpretation.	Chart 19 description

11. AMSTAR 2 Critical Domains Compliance

#	AMSTAR 2 Item	Critical?	How Addressed
1	PICO components for research question	No	Section 2 above
2	Protocol registered before commencement	Yes	This protocol tab (living protocol)
4	Comprehensive literature search strategy	Yes	Section 4: 3 databases + reference check; search strings visible
7	List of excluded studies with justifications	Yes	Screening tab: excluded with auto/manual reason
9	Satisfactory RoB assessment technique	Yes	Section 7: Cochrane RoB 2, 5 domains
11	Appropriate meta-analytical methods	Yes	Section 8: DL RE + HKSJ, R/Python cross-validated
13	RoB impact on results considered	Yes	GRADE domain 1, Extraction → RoB tab
15	Publication bias assessment	Yes	Section 9: Funnel + Egger + Trim-Fill + Copas

12. Reporting & Dissemination [PRISMA #23–27, AMSTAR #16]

Reporting Guideline	PRISMA 2020 (27-item checklist auto-generated as CSV)
Export Formats	CSV (study data), JSON (full state), R validation script, Python validation script, PRISMA checklist CSV, HTML standalone report
Data Integrity	SHA-256 data seal (cryptographic fingerprint) on every report; version timeline with delta alerts
Cross-Validation	R (`metafor`) and Python (`scipy`) scripts included for independent replication of pooled OR, CI, τ²
Patient Mode	Plain-language summary with traffic-light visual; hides technical statistics for lay audiences

Search History Log [PRISMA #8]

No searches recorded yet. Run an acquisition from the Search tab to log results here.

Evidence Acquisition

Multi-Source: ClinicalTrials.gov + PubMed + OpenAlex

Saved Search Log

No searches recorded yet.

PRISMA-NMA Flow Diagram

Pooled Odds Ratio (Random-Effects)

Precision (95% CI)

Heterogeneity (I²)

HKSJ-Adjusted CI

Prediction Interval

Q-test (Cochran)

τ² (95% CI)

Bayesian CrI

P(OR < 1)

Information Fraction

Bayesian Prior:

Meta-Regression:

Subgroup By:

Egger's: --

ROB-ME: --

Fragility: --

Trim-Fill: --

Selection Sensitivity: --

RIS: --

HR Sensitivity: --

Method Sensitivity: --

Study Characteristics

Trial	Year	Phase	Indication	N (Tx)	N (Ctrl)	ER Tx%	ER Ctrl%	RoB

ER = Event Rate. Values extracted from registry records — verify against published manuscripts before finalizing.

Precision Analytics Suite

1. Forest Plot (Fixed/Random Effects)

2. Subgroup Synthesis

3. Cumulative Meta-Analysis

4. Cumulative Z-Curve Analysis

5. Leave-One-Out Sensitivity

6. L'Abbe Plot (Event Incidence)

7. Galbraith Plot (Heterogeneity Check)

8. Clinical Utility (NNT Curve)

9. Funnel Plot (Publication Bias)

10. Baujat Plot (Influence x Heterogeneity)

11. Bayesian Posterior Density

12. Meta-Regression

13. Selection Sensitivity (Copas-inspired heuristic)

14. Conditional Power Curve

15. Egger's Regression Plot

16. Risk of Bias Summary

17. Method Sensitivity

18. Network Meta-Analysis (Exploratory League Table)

19. Safety Profile (CT.gov Adverse Events)

What does this mean for you?

This is a summary for general understanding. Always discuss with your healthcare provider.

9. Quality Appraisal (RoB 2.0)

WebR: Validate with R in Your Browser

Not loaded

Runs metafor::rma() directly in your browser via WebAssembly. No server needed. First load installs R + metafor (~20-40s).

10. Evidence Summary (GRADE)

TruthCert R-Metafor Script (DL Model)

R Cross-Validation (metafor v4.8)

Click "Validate" after running the analysis to compare JS engine output against R (metafor).

Auto-Generated Manuscript Text

Click "Generate Output" to create manuscript text.

Scientific Synthesis

Generating Visual Abstract & PRISMA Diagram...

PRISMA 2020 Flow Diagram (SVG)

DAPT De-Escalation / Short-DAPT after PCI

Multi-source meta-analysis of landmark RCTs

Patient Population

N = -- Patients

Acquisition Era

Post-2015 Enrollment

Primary HF Composite Result

Odds Ratio [95% CI]

Consistency (I²)

Scientific Verdict

Waiting Room Summary

--/100

NNT Pictogram

--%

Risk Change

Odds Ratio

For general understanding only. Discuss treatment decisions with your healthcare provider.

PRISMA 2020 Flow Diagram

Databases & Registers

Records from ClinicalTrials.gov
(n = --)

Records removed before screening
Duplicates / Ineligible
(n = --)

Records screened
(n = --)

Records excluded
(n = --)

Other Sources

Records from PubMed
(n = --)

Records from OpenAlex
(n = --)

Reference-checked trials
(n = --)

Reports assessed for eligibility
(n = --)

Reports excluded
(n = --)

Included in synthesis
(n = --)

The DAPT De-Esc Evidence

A quantitative synthesis of landmark randomized trials.

Pooled OR

NNT

I² Heterogeneity

Trials Included

Confidence Interval Comparison

Visual comparison of estimation methods on the odds ratio scale. The pooled point estimate is identical; interval widths differ by method.

Fig. — DerSimonian-Laird (standard), Hartung-Knapp-Sidik-Jonkman (adjusted), and Prediction Interval estimates

Publication-Quality Forest Plot

Annotated forest plot with trial-level statistics and weight contributions. Suitable for manuscript figures.

Fig. — Forest plot of Ticagrelor mono after 3mo DAPT and related agents vs comparator for composite cv death/mi/stroke/stent-thrombosis/timi bleeding composite (random-effects, DL estimator)

Summary of Findings

Outcome	No. Trials	Total N	Effect (OR)	95% CI	I²	GRADE

SoF table follows GRADE Working Group recommendations. Verify values against R validation script output.

GRADE Evidence Profile (Summary of Findings)

Cumulative Meta-Analysis

Click "Run Cumulative" to generate a cumulative meta-analysis ordered by publication year.

Quality Assurance (18 Checks)

Click "Run QA" to execute 18 automated quality checks on the current analysis.

Version Timeline

Generate a report to create the first snapshot.

Data Seal: -- · --