Choosing a perspective on mortality with DAPT.

Abstract

This editorial refers to ‘Causes of late mortality with dual antiplatelet therapy after coronary stents’[†][1], by L. Mauri et al ., on page 378 and ‘Ascertainment, classification, and impact of neoplasm detection during prolonged treatment with dual antiplatelet therapy with prasugrel vs. clopidogrel following acute coronary syndrome’,[‡][2] by M.T. Roe et al ., on page 412. Dual antiplatelet therapy (DAPT, a combination of aspirin and a P2Y12 inhibitor), typically for up to 1 year, has been shown to be of benefit in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) and stable coronary artery disease (SCAD). After this period, however, there remains a significant incidence of ischaemic events, particularly in high-risk patients, and extending the duration of DAPT has been explored as a potential way of reducing these further. The DAPT study randomized, at 12 months after PCI, 9961 patients treated with drug-eluting stents (DES; the primary analysis cohort) and 1287 patients treated with bare-metal stents to a further 18 months of thienopyridine (clopidogrel in 65%, prasugrel in 35%) or placebo.1 The co-primary outcomes of stent thrombosis and major adverse cardiovascular/cerebrovascular events (MACCE) were both significantly less frequent in the extended DAPT group. Moderate or severe, but not fatal, bleeding was also significantly higher in this group. This was perhaps as expected; however, an unanticipated finding was of higher non-cardiovascular causes of death [1.1% vs. 0.6%, hazard ratio (HR) 1.80, P = 0.01] in the DES cohort treated with extended DAPT. There were more cancer-related deaths in the thienopyridine group, although a greater number of patients with previously diagnosed malignancy entered into this arm. There … [1]: #fn-2 [2]: #fn-3