Grabbing the Horns of a Dilemma

Abstract

Despite the overwhelming success of percutaneous cardiac interventions, the interventional practitioner is commonly faced with a number of very simple questions, the answers of which should be obvious but in truth are completely unknown. Perhaps the most common such question concerns the appropriate duration of dual antiplatelet therapy (the combination of aspirin and an inhibitor of platelet P2Y12) in patients who have received intracardiac stents. Most interventional cardiologists receive several such calls per week from patients and professional colleagues and often have to spend a considerable amount of time negotiating antithrombotic drug treatment strategies in patients who need to undergo noncardiac surgical procedures. Article see p 2015 The truth is that as we enter the third decade of stent use, we know much less about the need for antithrombotic therapy after stent implantation than we (and our patients) would like. Much of our current knowledge is derived from early studies in patients receiving bare metal stents. When stents were first implanted, the recommended antithrombotic therapy included a variety of marginally effective antiplatelet therapies and toxic doses of warfarin and heparin. In 1995, Colombo et al1 observed that optimization of stent deployment with ultrasound followed by treatment with aspirin and ticlopidine was associated with lower rates of stent thrombosis, less bleeding, and shorter hospital stays than historical reports. We probably never would have entered the modern stent era without these important observations, which were rapidly confirmed by a series of randomized trials.2 However, the appropriate duration of thienopyridine therapy after stenting was unknown. Whereas 1 report indicated that a 2-week course might be sufficient,3 the randomized Clopidogrel for the Reduction of Events During Observation (CREDO) trial showed that a year of dual antiplatelet therapy reduced the rate of a combined end point of death, myocardial infarction, or …