Balancing ischaemia and bleeding with dual antiplatelet therapy: a resolute endeavour

Abstract

This editorial refers to ‘Modifying effect of dual antiplatelet therapy on incidence of stent thrombosis according to implanted drug-eluting stent type’[†][1], by E. Camenzind et al. , on page 1932 and ‘Lack of association between dual antiplatelet therapy use and stent thrombosis between 1 and 12 months following Resolute zotarolimus-eluting stent implantation’[‡][2], by S. Silber et al. , on page 1949. The most devastating complication after stent implantation is sudden, thrombotic coronary occlusion, which results in myocardial infarction (MI) in 80–90% of patients and death in 20–30%. Dual antiplatelet therapy (DAPT) with aspirin and an ADP receptor antagonist is the foundation to prevent stent thrombosis (ST).1 Whereas drug-eluting stents (DES) are more effective than bare metal stents (BMS) in preventing restenosis and recurrent ischaemia, DES susceptibility to ST is increased by delayed endothelialization, polymer hypersensitivity, and other mechanisms,2 necessitating prolonged DAPT. Long-term DAPT may have additional benefits by preventing atherothrombotic events in patients with vascular disease.3 However, DAPT increases major bleeding, the occurrence of which is strongly associated with subsequent mortality.4 Striking the right balance between ischaemic and bleeding complications by fine-tuning the potency and duration of DAPT is essential to optimize DES outcomes. First-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES) were approved based on the basis of double-blind randomized trials in which DAPT was used for 3–6 months. Thereafter, reports of late ST resulted in recommendations for DAPT for 1 year or longer, without randomized evidence to support this endorsement. These guidelines have been carried forward to newer generation DES, despite randomized trials demonstrating enhanced safety and effectiveness with these devices compared with their earlier … [1]: #fn-2 [2]: #fn-3