Dual antiplatelet treatment after stenting: is longer better?

Abstract

During the past decade, drug-eluting stents (DES) have emerged as a preferred and highly effective treatment for patients with symptomatic coronary artery disease. Stent thrombosis, the Achilles heel of DES implantation, continues to be a relevant issue that needs to be prevented with dual antiplatelet treatment (DAPT) consisting of aspirin and a P2Y12 receptor inhibitor. Guidelines recommend (class IB) a DAPT duration of 6–12 months for stable patients with coronary artery disease 1 Montalescot G Sechtem U Achenbach S et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013; 34: 2949-3003 Crossref PubMed Scopus (3648) Google Scholar who are undergoing elective percutaneous coronary intervention (PCI) with a second-generation everolimus-eluting or zotarolimus-eluting DES, and a DAPT duration of 12 months (class IA) in patients with acute coronary syndrome 2 Hamm CW Bassand JP Agewall S et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011; 32: 2999-3054 Crossref PubMed Scopus (3026) Google Scholar unless there are contraindications such as an excessive risk of bleeding. Such recommendations on DAPT duration are based on limited data from clinical trials. Extension of DAPT might mitigate risk of stent thrombosis or subsequent thrombotic events elsewhere in the circulation. However, it will also increase bleeding risk and costs. Therefore, a key question that remained to be addressed by adequately powered clinical trials is whether or not extension of DAPT beyond 1 year after PCI provides any net clinical benefit. Dual-antiplatelet treatment beyond 1 year after drug-eluting stent implantation (ARCTIC-Interruption): a randomised trialOur finding suggests no apparent benefit but instead harm with extension of DAPT beyond 1 year after stenting with DES when no event has occurred within the first year after stenting. No conclusion can be drawn for high-risk patients who could not be randomised. The consistency between findings from all trials of such interruption suggests the need for a reappraisal of guidelines for DAPT after coronary stenting towards shorter duration of treatment. Full-Text PDF