2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Abstract

See Editorial Commentary page 1276. See Editorial Commentary page 1276. Incorporation of new study results, medications, or devices that merit modification of existing clinical practice guideline recommendations, or the addition of new recommendations, is critical to ensuring that guidelines reflect current knowledge, available treatment options, and optimum medical care. To keep pace with evolving evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines (“Task Force”) has issued this focused update to revise existing guideline recommendations on the basis of recently published study data. This update has been subject to rigorous, multilevel review and approval, similar to the full guidelines. For specific focused update criteria and additional methodological details, please see the ACC/AHA guideline methodology manual.1ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. American College of Cardiology and American Heart Association. Accessed January 23, 2015.Google Scholar Processes have evolved over time in response to published reports from the Institute of Medicine2Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (US)Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Google Scholar, 3Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (US)Finding What Works in Health Care: Standards for Systematic Reviews. National Academies Press, Washington, DC2011Google Scholar and ACC/AHA mandates,4Anderson J.L. Heidenreich P.A. Barnett P.G. et al.ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.Circulation. 2014; 129: 2329-2345Crossref PubMed Scopus (35) Google Scholar, 5Arnett D.K. Goodman R.A. Halperin J.L. et al.AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services.Circulation. 2014; 130: 1662-1667Crossref PubMed Scopus (16) Google Scholar, 6Jacobs A.K. Kushner F.G. Ettinger S.M. et al.ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 127: 268-310Crossref PubMed Scopus (35) Google Scholar, 7Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (25) Google Scholar leading to adoption of a “knowledge byte” format. This process entails delineation of a recommendation addressing a specific clinical question, followed by concise text (ideally <250 words per recommendation) and hyperlinked to supportive evidence. This approach better accommodates time constraints on busy clinicians, facilitates easier access to recommendations via electronic search engines and other evolving technology, and supports the evolution of guidelines as “living documents” that can be dynamically updated as needed. The Class of Recommendation (COR) and Level of Evidence (LOE) are derived independently of each other according to established criteria. The COR indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit of a clinical action in proportion to risk. The LOE rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 1). Recommendations in this focused update reflect the new 2015 COR/LOE system, in which LOE B and C are subcategorized for the purpose of increased granularity.1ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. American College of Cardiology and American Heart Association. Accessed January 23, 2015.Google Scholar, 7Jacobs A.K. Anderson J.L. Halperin J.L. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: 1208-1217Crossref PubMed Scopus (25) Google Scholar, 8Halperin J.L. Levine G.N. Al-Khatib S.M. et al.Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2016; 133: 1426-1428Crossref PubMed Scopus (5) Google ScholarTable 1Applying class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care∗ (updated August 2015) Open table in a new tab The ACC and AHA exclusively sponsor the work of guideline writing committees (GWCs) without commercial support, and members volunteer time for this activity. Selected organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All GWC members and reviewers are required to fully disclose current industry relationships or personal interests, beginning 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced GWC and requires that both the chair and a majority of GWC members have no relevant RWI (see Appendix 1 for the definition of relevance). GWC members are restricted with regard to writing or voting on sections to which RWI apply. Members of the GWC who recused themselves from voting are indicated and specific section recusals are noted in Appendixes 1 and 2. In addition, for transparency, GWC members' comprehensive disclosure information is available as an Online Supplement (http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIR.0000000000000404/-/DC1). Comprehensive disclosure information for the Task Force is also available at http://www.acc.org/about-acc/leadership/guidelines-and-documents-task-forces.aspx. The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, genders, ethnicities, intellectual perspectives, and scopes of clinical activities. Guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a broader target. Although guidelines may be used to inform regulatory or payer decisions, the intent is to improve quality of care and align with patients' interests. The guidelines are reviewed annually by the Task Force and are official policy of the ACC and AHA. Each guideline is considered current unless and until it is updated, revised, or superseded by a published addendum. For additional information pertaining to the methodology for grading evidence, assessment of benefit and harm, shared decision making between the patient and clinician, structure of evidence tables and summaries, standardized terminology for articulating recommendations, organizational involvement, peer review, and policies regarding periodic assessment and updating of guideline documents, we encourage readers to consult the ACC/AHA guideline methodology manual.1ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. American College of Cardiology and American Heart Association. Accessed January 23, 2015.Google Scholar Jonathan L. Halperin, MD, FACC, FAHA, Chair, ACC/AHA Task Force on Clinical Practice Guidelines The scope of this focused update is limited to addressing recommendations on duration of dual antiplatelet therapy (DAPT) (aspirin plus a P2Y12 inhibitor) in patients with coronary artery disease (CAD). Recommendations considered are those in 6 guidelines: “2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention,”9Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (590) Google Scholar “2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery,”10Hillis L.D. Smith P.K. Anderson J.L. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesDeveloped in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.Circulation. 2011; 124: e652-e735Crossref PubMed Scopus (222) Google Scholar “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease,”11Fihn S.D. Blankenship J.C. Alexander K.P. et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2014; 130: 1749-1767Crossref PubMed Scopus (64) Google Scholar, 12Fihn S.D. Gardin J.M. Abrams J. et al.2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: 3097-3137Crossref PubMed Scopus (86) Google Scholar “2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction,”13O'Gara P.T. Kushner F.G. Ascheim D.D. et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 127: e362-e425Crossref PubMed Scopus (260) Google Scholar “2014 ACC/AHA Guideline for Non–ST-Elevation Acute Coronary Syndromes,”14Amsterdam E.A. Wenger N.K. Brindis R.G. et al.2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: e344-e426Crossref PubMed Scopus (113) Google Scholar and “2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.”15Fleisher L.A. Fleischmann K.E. Auerbach A.D. et al.2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: e278-e333Crossref PubMed Scopus (51) Google Scholar The impetus for this focused update review is 11 studies16Mauri L. Kereiakes D.J. Yeh R.W. et al.Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents.N Engl J Med. 2014; 371: 2155-2166Crossref PubMed Scopus (357) Google Scholar, 17Colombo A. Chieffo A. Frasheri A. et al.Second-generation drug-eluting stent implantation followed by 6- versus 12-month dual antiplatelet therapy: the SECURITY randomized clinical trial.J Am Coll Cardiol. 2014; 64: 2086-2097Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 18Gwon H.-C. Hahn J.-Y. Park K.W. et al.Six-month versus 12-month dual antiplatelet therapy after implantation of drug-eluting stents: the Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting (EXCELLENT) randomized, multicenter study.Circulation. 2012; 125: 505-513Crossref PubMed Scopus (227) Google Scholar, 19Kim B.-K. Hong M.-K. Shin D.-H. et al.A new strategy for discontinuation of dual antiplatelet therapy: the RESET Trial (REal Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation).J Am Coll Cardiol. 2012; 60: 1340-1348Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar, 20Feres F. Costa R.A. Abizaid A. et al.Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial.JAMA. 2013; 310: 2510-2522PubMed Google Scholar, 21Schulz-Schüpke S. Byrne R.A. Ten Berg J.M. et al.ISAR-SAFE: a randomized, double-blind, placebo-controlled trial of 6 vs. 12 months of clopidogrel therapy after drug-eluting stenting.Eur Heart J. 2015; 36: 1252-1263Crossref PubMed Scopus (80) Google Scholar, 22Park S.-J. Park D.-W. Kim Y.-H. et al.Duration of dual antiplatelet therapy after implantation of drug-eluting stents.N Engl J Med. 2010; 362: 1374-1382Crossref PubMed Scopus (331) Google Scholar, 23Valgimigli M. Campo G. Monti M. et al.Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: a randomized multicenter trial.Circulation. 2012; 125: 2015-2026Crossref PubMed Scopus (300) Google Scholar, 24Collet J.-P. Silvain J. Barthélémy O. et al.Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): a randomised trial.Lancet. 2014; 384: 1577-1585Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 25Gilard M. Barragan P. Noryani A.A.L. et al.6- versus 24-month dual antiplatelet therapy after implantation of drug-eluting stents in patients nonresistant to aspirin: the randomized, multicenter ITALIC trial.J Am Coll Cardiol. 2015; 65: 777-786Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 26Lee C.W. Ahn J.-M. Park D.-W. et al.Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a randomized, controlled trial.Circulation. 2014; 129: 304-312Crossref PubMed Scopus (88) Google Scholar, 27Helft G. Steg P.G. Le Feuvre C. et al.Stopping or continuing clopidogrel 12 months after drug-eluting stent placement: the OPTIDUAL randomized trial.Eur Heart J. 2016; 37: 365-374PubMed Google Scholar of patients treated with coronary stent implantation (predominantly with drug-eluting stents [DES]) assessing shorter-duration or longer-duration DAPT, as well as a large, randomized controlled trial (RCT) of patients 1 to 3 years after myocardial infarction (MI) assessing the efficacy of DAPT compared with aspirin monotherapy.28Bonaca M.P. Bhatt D.L. Cohen M. et al.Long-term use of ticagrelor in patients with prior myocardial infarction.N Engl J Med. 2015; 372: 1791-1800Crossref PubMed Scopus (198) Google Scholar These studies were published after the formulation of recommendations for duration of DAPT in prior guidelines. The specific mandate of the present writing group is to evaluate, update, harmonize, and, when possible, simplify recommendations on duration of DAPT. Although there are several potential combinations of antiplatelet therapy, the term and acronym DAPT has been used to specifically refer to combination antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) and will be used similarly in this focused update. Recommendations in this focused update on duration of DAPT, aspirin dosing in patients treated with DAPT, and timing of elective noncardiac surgery in patients treated with percutaneous coronary intervention (PCI) and DAPT supersede prior corresponding recommendations in the 6 relevant guidelines. These recommendations for duration of DAPT apply to newer-generation stents and, in general, only to those not treated with oral anticoagulant therapy. For the purposes of this focused update, patients with a history of acute coronary syndrome (ACS) >1 year prior who have since remained free of recurrent ACS are considered to have transitioned to stable ischemic heart disease (SIHD) and are addressed in the section on SIHD. Issues and recommendations with regard to P2Y12 inhibitor “pretreatment,” “preloading,” and loading are beyond the scope of this document but are addressed in other guidelines.9Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (590) Google Scholar, 14Amsterdam E.A. Wenger N.K. Brindis R.G. et al.2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2014; 130: e344-e426Crossref PubMed Scopus (113) Google Scholar, 29Roffi M. Patrono C. Collet J.-P. et al.2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC).Eur Heart J. 2016; 37: 267-315Crossref PubMed Scopus (143) Google Scholar This focused update is designed to function both as a standalone document and to serve as an update to the relevant sections on duration of DAPT in the 6 clinical practice guidelines, replacing relevant text, figures, and recommendations. Thus, by necessity, there is some redundancy in different sections of this document. When possible, the “knowledge byte” format was used for recommendations. In some cases, the complexity of this document required a modification of the knowledge byte format, with several interrelated recommendations grouped together, followed by concise associated text (<250 words of text per recommendation). Clinical trials published since the 2011 PCI guideline9Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (590) Google Scholar and the 2011 coronary artery bypass graft (CABG) guideline,10Hillis L.D. Smith P.K. Anderson J.L. et al.2011 ACCF/AHA guideline for coronary artery bypass graft surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice GuidelinesDeveloped in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.Circulation. 2011; 124: e652-e735Crossref PubMed Scopus (222) Google Scholar published in a peer-reviewed format through December 2015, were reviewed by the Task Force to identify trials and other key data that might affect guideline recommendations. The information considered important enough to prompt updated recommendations is included in evidence tables in the Online Data Supplement. In accord with recommendations by the Institute of Medicine2Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (US)Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Google Scholar, 3Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (US)Finding What Works in Health Care: Standards for Systematic Reviews. National Academies Press, Washington, DC2011Google Scholar and the ACC/AHA Task Force Methodology Summit,1ACCF/AHA Task Force on Practice Guidelines. Methodology Manual and Policies From the ACCF/AHA Task Force on Practice Guidelines. Available at: http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://my.americanheart.org/idc/groups/ahamah-public/@wcm/@sop/documents/downloadable/ucm_319826.pdf. American College of Cardiology and American Heart Association. Accessed January 23, 2015.Google Scholar, 6Jacobs A.K. Kushner F.G. Ettinger S.M. et al.ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 127: 268-310Crossref PubMed Scopus (35) Google Scholar 3 critical (PICOTS-formatted; population, intervention, comparison, outcome, timing, setting) questions were developed to address the critical questions related to duration of DAPT. These 3 critical questions were the basis of a formal systematic review and evaluation of the relevant study data by an Evidence Review Committee (ERC).30Bittl J.A. Baber U. Bradley S.M. et al.Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2016; 134: e123-e155Crossref PubMed Google Scholar Concurrent with this process, writing group members evaluated study data relevant to the numerous current recommendations in the 6 guidelines, including topics not covered in the 3 critical questions (eg, DAPT after CABG). The findings of the ERC and the writing group members were formally presented and discussed, and then modifications to existing recommendations were considered. Recommendations that are based on a body of evidence that includes a systematic review conducted by the ERC are denoted by the superscript SR (eg, LOE B-R SR). See the ERC systematic review report, “Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease,” for the complete evidence review report.30Bittl J.A. Baber U. Bradley S.M. et al.Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2016; 134: e123-e155Crossref PubMed Google Scholar Recommendations on duration of DAPT are currently included in 6 clinical practice guidelines, which are interrelated and overlapping because they address the management of patients with CAD. Therefore, the writing group consisted of the chairs/vice chairs and/or members of all 6 guidelines, representing the fields of cardiovascular medicine, interventional cardiology, cardiac surgery, internal medicine, and cardiovascular anesthesia, as well as expertise in trial design and statistical analysis. This focused update was reviewed by the writing committee members from the 6 guidelines; by 5 official reviewers from the ACC and AHA; 2 reviewers each from the American Association for Thoracic Surgery, American College of Emergency Physicians, American Society of Anesthesiologists, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and the Society of Thoracic Surgeons; and by 23 additional content reviewers. Reviewers' RWI information is published in this document (Appendix 2). This document was approved for publication by the governing bodies of the ACC and the AHA and was endorsed by the American Association for Thoracic Surgery, American Society of Anesthesiologists, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, Society of Thoracic Surgeons, and Society for Vascular Surgery. The 3 critical (PICOTS-formatted) questions on DAPT duration are listed in Table 2. Most contemporary studies of DAPT have compared either shorter (3 to 6 months)17Colombo A. Chieffo A. Frasheri A. et al.Second-generation drug-eluting stent implantation followed by 6- versus 12-month dual antiplatelet therapy: the SECURITY randomized clinical trial.J Am Coll Cardiol. 2014; 64: 2086-2097Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 18Gwon H.-C. Hahn J.-Y. Park K.W. et al.Six-month versus 12-month dual antiplatelet therapy after implantation of drug-eluting stents: the Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting (EXCELLENT) randomized, multicenter study.Circulation. 2012; 125: 505-513Crossref PubMed Scopus (227) Google Scholar, 19Kim B.-K. Hong M.-K. Shin D.-H. et al.A new strategy for discontinuation of dual antiplatelet therapy: the RESET Trial (REal Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation).J Am Coll Cardiol. 2012; 60: 1340-1348Abstract Full Text Full Text PDF PubMed Scopus (195) Google Scholar, 20Feres F. Costa R.A. Abizaid A. et al.Three vs twelve months of dual antiplatelet therapy after zotarolimus-eluting stents: the OPTIMIZE randomized trial.JAMA. 2013; 310: 2510-2522PubMed Google Scholar, 21Schulz-Schüpke S. Byrne R.A. Ten Berg J.M. et al.ISAR-SAFE: a randomized, double-blind, placebo-controlled trial of 6 vs. 12 months of clopidogrel therapy after drug-eluting stenting.Eur Heart J. 2015; 36: 1252-1263Crossref PubMed Scopus (80) Google Scholar or longer (18 to 48 months)16Mauri L. Kereiakes D.J. Yeh R.W. et al.Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents.N Engl J Med. 2014; 371: 2155-2166Crossref PubMed Scopus (357) Google Scholar, 22Park S.-J. Park D.-W. Kim Y.-H. et al.Duration of dual antiplatelet therapy after implantation of drug-eluting stents.N Engl J Med. 2010; 362: 1374-1382Crossref PubMed Scopus (331) Google Scholar, 23Valgimigli M. Campo G. Monti M. et al.Short- versus long-term duration of dual-antiplatelet therapy after coronary stenting: a randomized multicenter trial.Circulation. 2012; 125: 2015-2026Crossref PubMed Scopus (300) Google Scholar, 24Collet J.-P. Silvain J. Barthélémy O. et al.Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): a randomised trial.Lancet. 2014; 384: 1577-1585Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 25Gilard M. Barragan P. Noryani A.A.L. et al.6- versus 24-month dual antiplatelet therapy after implantation of drug-eluting stents in patients nonresistant to aspirin: the randomized, multicenter ITALIC trial.J Am Coll Cardiol. 2015; 65: 777-786Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 26Lee C.W. Ahn J.-M. Park D.-W. et al.Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a randomized, controlled trial.Circulation. 2014; 129: 304-312Crossref PubMed Scopus (88) Google Scholar duration of therapy with 12 months of DAPT, which is the recommended or minimal duration of therapy for most patients in ACC/AHA9Levine G.N. Bates E.R. Blankenship J.C. et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.Circulation. 2011; 124: e574-e651Crossref PubMed Scopus (590) Google Scholar, 13O'Gara P.T. Kushner F.G. Ascheim D.D. et al.2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 127: e362-e425Crossref PubMed Scopus (260) Google Scholar, 14Amsterdam E.A. Wenger N.K. Brindis R.G. et al.2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Pr