Individualizing Duration of Dual Antiplatelet Therapy After Acute Coronary Syndrome or Percutaneous Coronary Intervention.

Abstract

Clinical Presentation 1: A 68-year-old man with a history of treated dyslipidemia was admitted with non–ST-segment–elevation myocardial infarction (MI). Coronary angiography showed a thrombotic subtotal occlusion of the proximal dominant right coronary artery and 50% stenosis in the mid left anterior descending and first obtuse marginal arteries. He underwent percutaneous coronary intervention (PCI) to the proximal right coronary artery with a second-generation drug-eluting stent (DES). How do you decide on the duration of dual antiplatelet therapy (DAPT) in this individual? Clinical Presentation 2: An 81-year-old woman weighing 52 kg with a history of hypertension and gastroesophageal reflux disease presented with Canadian Cardiovascular Society class III stable angina. Myocardial perfusion imaging showed a moderate area of anterior ischemia. At coronary angiography, she had an eccentric 95% calcified lesion in the mid left anterior descending artery. She also had mild disease (≈30% stenosis) in the proximal right coronary and mid left circumflex coronary arteries. The left anterior descending artery was stented with a second-generation DES. How do you apply the evidence for DAPT in this patient? DAPT with aspirin and a P2Y12 receptor inhibitor is an essential component of the treatment of patients with acute coronary syndromes (ACS) and those undergoing PCI. DAPT after ACS reduces death and MI compared with aspirin alone, both in patients treated with PCI and in those who are managed conservatively.1–3 After elective PCI for stable coronary disease, DAPT reduces ischemic events and stent thrombosis (ST).4,5 However, these benefits come at the cost of increased risk of bleeding,6 raising the question about how to best balance efficacy and safety in determining the duration of DAPT. ### What Is the Evidence? Current treatment guidelines recommend 1 year of DAPT after ACS.7–9 This recommendation is based largely on the duration of treatment in …