Prolonged Dual Antiplatelet Therapy Research Articles

Abstract 19660: Scoring System to Predict Major Bleeding Complications in Atrial Fibrillation Patients With Oral Anticoagulant After Drug-eluting Stent Implantation

Background: We aimed to introduce scoring system to predict major bleeding complications after triple antithrombotic therapy (TAT) in patients with atrial fibrillation (AF) and drug-eluting stent (DES) implantation. Methods: Between April 2007 and December 2011, 119 patients with AF and DES implantation were enrolled in this study. All of these patients received oral anticoagulant therapy and dual antiplatelet therapy (DAPT). We investigated the incidence of major bleeding complications including intracranial and gastrointestinal bleeding. Each variables which seem to be associated with major bleeding complications were analyzed using the univariate logistic regression model. All variables tested in univariate analysis with p<0.10 were included in multivariate logistic regression model. The scores for each variables were transformed from regression coefficients and computed in a total score. Results: The mean follow-up period was 43.6 ± 25.5 month. The incidence of major bleeding was 17.6%. In multivariate analysis, age > 75 (OR 3.67, 95%CI 1.01-13.3, p = 0.048), continuation of DAPT (OR 7.85, 95%CI 1.50-41.2, p = 0.015), INR > 2.2 (OR 9.19, 95%CI 2.65-31.9, p < 0.001) were predictors of major bleeding complications. Each item’s score ranged from 0 to 2 and the total score ranged from 0 to 5. The area under the receiver operating characteristics curve revealed that there was 82.8% accuracy in the total scores predicting the likelihood of major bleeding complications. The rate of major bleeding complications was 2.3% in low-risk group (scores 0-1), 20.0% in moderate-risk group (scores 2-3), and 53.3% in high-risk group (scores 4-5) (p<0.001). Conclusions: This scoring system is useful for the risk stratification of major bleeding complications in AF patients with TAT after DES implantation.

Abstract 11515: Does Prolonged Dual Antiplatelet Therapy Increase Mortality After Drug-Eluting Stent Implantation?

Introduction: The Dual Antiplatelet Therapy (DAPT) trial found a borderline increase in the rate of all-cause mortality in patients treated with 30 compared with 12 months of DAPT (2.0% vs. 1.5%, HR 1.36, 95% CI 1.00-1.85, P = 0.05). Hypothesis: A finding of borderline significance in a mega-trial may reflect the play of chance. Methods: We used a Bayesian conjugate-normal approach (Figure A) to update the mortality results from the DAPT trial with an empiric prior probability distribution based on results in 9 smaller randomized controlled trials (RCTs). Results: The empiric prior (blue), which suggests that the odds of mortality in the 9 smaller RCTs could be 6% lower or as much as 40% higher after prolonged than after short DAPT, overlaps with the likelihood (red) from the DAPT trial itself. Bayesian inference (black) affirms a significant increase in mortality with prolonged DAPT (posterior mean odds ratio [OR] 1.21, 95% Bayesian confidence interval [BCI] 1.02-1.44). Sensitivity analysis, which weighs the number of effective events by the proportion of patients with acute coronary syndromes, produces a nearly identical point estimate (OR 1.23, 95% BCI 0.96-1.58). Conclusions: Our analysis provides credible evidence that 30 months of DAPT is associated with higher mortality rates than is 12 months of therapy. The mortality increase in the DAPT trial is predictable from prior RCTs and not likely to be a chance finding.

Abstract 15408: Long-term Antithrombotic Management Patterns After Acute Coronary Syndromes: 2-[[Unsupported Character - Codename ­]]years Follow-up in the EPICOR Asia Study

Introduction: Guidelines recommend dual-antiplatelet therapy (DAPT) for 12 months in patients with acute coronary syndromes (ACS). Information on patterns and duration of DAPT use after hospital discharge in ACS patients in Asia is sparse. Objective: We describe changes in real-life antithrombotic management patterns (AMPs) up to 2-y post discharge based on data from the EPICOR Asia study (NCT01361386). Methods: This observational study enrolled 12 922 hospital survivors post ACS from 218 hospitals in 8 countries/regions in Asia. Data were collected from symptom onset for the index event (ST-segment elevation myocardial infarction [STEMI] 51.2%, non-STEMI (NSTEMI) 19.9%, or unstable angina [UA] 28.9%), during hospitalization, at discharge and over 2 y follow-up. Results: Overall, 90.6% of patients were on DAPT at hospital discharge which declined to 79.6%, 71.8%, 53.7%, and 45.6% at 6, 12, 18, and 23 months post discharge (Fig). At discharge, most patients (87.6%) received aspirin + clopidogrel, with 79.5%, 71.8%, 53.6%, and 45.4% on this combination at 6, 12, 18, and 23 months. At discharge only 3.0% of patients received aspirin + prasugrel and 1.7% of patients received aspirin + cilostazol. Only 8.3% of patients were on single antiplatelet therapy (SAPT) at discharge with 12.2%, 15.6%, 28.1%, and 30.3% on SAPT at 6, 12, 18, and 23 months post discharge; aspirin being the most commonly used single agent. No notable differences were seen among index event groups. Of the patients on DAPT at discharge, STEMI 93.4%; NSTEMI 90.2%; UA 85.9%, comparable proportions across groups remained on DAPT at 23 months follow up; STEMI 51.0%; NSTEMI 51.9%; UA 47.6%. Conclusions: Most ACS patients remain on DAPT at 12 months and around half remain at 23 months post-discharge. Further study should assess between-country differences, the benefit/risk balance from prolonged DAPT, why DAPT is discontinued before 12 months, and impact on clinical outcomes.

Abstract 13179: Bare Metal vs Drug Eluting Stent Choice: The Impact of Atrial Fibrillation and Setting of Care Among Medicare Beneficiaries

Background: In treating coronary artery disease, many factors influence the choice of bare metal (BMS) or drug eluting stents (DES), including bleeding risk and suitability for prolonged dual anti-platelet therapy (DAPT). Atrial fibrillation (AF) further complicates this choice. We examined stent selection among Medicare beneficiaries by AF status to explore how cardiologists are managing this complex choice overall and how this choice varies across academic medical centers (AMC). Methods: Using a 100% Medicare denominator file and associated inpatient claims (2008-2012), we identified patients over age 65 receiving inpatient coronary artery stents. We measured BMS and DES use in AF and non-AF patients overall and assessed variation in stent choice across 50 high volume AMCs. Results: Overall, 1,269,239 stent procedures were studied. BMS, as a percent of total inpatient stents, declined from 2008 to 2012 in AF (41% to 34%) and non-AF (30% to 21%) patients. Across high volume AMCs in 2012, the proportion of stent patients receiving BMS (5th to 95th percentile) ranged from 15% to 63% in AF patients and from 8% to 37% in non-AF patients. In 2012, the AMC-level difference in BMS stent use by AF status (proportion of BMS among AF patients minus proportion BMS in non-AF patients) ranged from 4% to 35% (5th to 95th percentile). Conclusions: Among stent recipients, AF patients are more likely to receive BMS than non-AF patients but treatment varies widely across AMCs, suggesting a lack of consensus. Studies of stent choice and outcomes among AF patients are needed to guide care decisions and optimize outcomes.

Abstract 11774: Beyond Restenosis - Patients’ Preferences for Drug Eluting versus Bare Metal Stents

Introduction: Drug eluting stents (DES) reduce the need for target vessel revascularization, and are used in ~80% of percutaneous coronary interventions (PCI) in the US. However, DES also necessitate the use of prolonged dual anti-platelet therapy (DAPT), which is associated with increased bleeding/bruises, can complicate future surgeries and can increase patients’ medication costs (DAPT drawbacks). Patients’ preferences regarding the benefits of DES and DAPT drawbacks have not previously been studied or reported. Methods: In a prospective, observational cohort study, consecutive patients undergoing PCI at 2 Kansas City hospitals completed a survey assessing the importance of the following factors related to the decision to receive DES: need for repeat PCI and DAPT drawbacks. Each factor was rated from 1 (not important) to 10 (extremely important). The most important factor, or group of factors, to each patient was then identified. Results: Among 317 PCI patients (66% male, 71% white, 45% DM, 80% HTN, 43% with prior PCI), 21% did not consider the need for repeat PCI as the most important factor (Figure). Only 14% considered the need for repeat PCI the single most important factor and 65% considered at least one DAPT drawback as important as repeat PCI. A third (32.8%) ranked minor bleeding/bruising as the most important factor (alone (5.5%) or with other domains (27.3%)). Conclusions: While the need for repeat PCI is an important factor to patients considering stent options, 85% of PCI patients regard other factors to be at least as important. Eliciting patients’ preferences is important to better tailor stent choices to the goals and values of individual patients undergoing PCI.

One-year outcome of a prospective trial stopping dual antiplatelet therapy at 3months after everolimus-eluting cobalt-chromium stent implantation: ShortT and OPtimal duration of Dual AntiPlatelet Therapy after everolimus-eluting cobalt-chromium stent (STOPDAPT) trial.

There has been no previous prospective study evaluating dual antiplatelet therapy (DAPT) duration shorter than 6 months after cobalt-chromium everolimus-eluting stent (CoCr-EES) implantation. STOPDAPT trial is a prospective multi-center single-arm study evaluating 3-month DAPT duration after CoCr-EES implantation. The primary endpoint was a composite of cardiovascular death, myocardial infarction (MI), stroke, definite stent thrombosis (ST) and TIMI major/minor bleeding at 1 year. Between September 2012 and October 2013, a total of 1525 patients were enrolled from 58 Japanese centers, with complete 1-year follow-up in 1519 patients (99.6 %). Thienopyridine was discontinued within 4 months in 1444 patients (94.7 %). The event rates beyond 3 months were very low (cardiovascular death: 0.5 %, MI: 0.1 %, ST: 0 %, stroke: 0.7 %, and TIMI major/minor bleeding: 0.8 %). Cumulative 1-year incidence of the primary endpoint was 2.8 % [upper 97.5 % confidence interval (CI) 3.6 %], which was lower than the pre-defined performance goal of 6.6 % (P < 0.0001). Using the CoCr-EES group in the RESET trial as a historical comparison group, where nearly 90 % of patients had continued DAPT at 1 year, cumulative incidence of the primary endpoint tended to be lower in the STOPDAPT than in the RESET (2.8 versus 4.0 %, P = 0.06) and adjusted hazard ratio was 0.64 (95 % CI 0.42–0.95, P = 0.03). The cumulative incidence of definite/probable ST was lower in the STOPDAPT than in the RESET [0 patient (0 %) versus 5 patients (0.3 %), P = 0.03]. In conclusion, stopping DAPT at 3 months in selected patients after CoCr-EES implantation was at least as safe as the prolonged DAPT regimen adopted in the historical control group.Electronic supplementary materialThe online version of this article (doi:10.1007/s12928-015-0366-9) contains supplementary material, which is available to authorized users.

Extended Duration Dual Antiplatelet Therapy and Mortality: A Systematic Review and Meta-Analysis

Background Treatment with aspirin and a P2Y12 inhibitor is commonly used in patients with cardiovascular disorders. The overall eff ect of such treatment on all-cause mortality is unknown. In the Dual Antiplatelet Therapy (DAPT) Study , continuation of dual antiplatelet therapy beyond 12 months after coronary stenting was associated with an unexpected increase in non-cardiovascular death. In view of the potential public health importance of these fi ndings, we aimed to assess the eff ect of extended duration dual antiplatelet therapy on mortality by doing a meta-analysis of all randomised, controlled trials of treatment duration in various cardiovascular disorders. Methods We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomised controlled trials assessing the eff ect of extended duration versus no or short duration dual antiplatelet therapy , published before Oct 1, 2014. We did a meta-analysis to pool results with a hierarchical Bayesian randomeff ects model. The primary outcomes were hazard ratios comparing rates of all-cause, cardiovascular, and noncardiovascular death. Findings Including the DAPT Study, we identifi ed 14 eligible trials that randomly assigned 69 644 participants to diff erent durations of dual antiplatelet therapy. Compared with aspirin alone or short duration dual antiplatelet therapy (≤6 months), continued treatment was not associated with a diff erence in all-cause mortality (hazard ratio [HR] 1·05, 95% credible interval [CrI] 0·96–1·19; p=0·33). Similarly, cardiovascular (1·01, 0·93–1·12; p=0·81) and non-cardiovascular mortality (1·04, 0·90–1·26; p=0·66) were no diff erent with extended duration versus short duration dual antiplatelet therapy or aspirin alone. Interpretation Extended duration dual antiplatelet therapy was not associated with a diff erence in the risk of all-cause, cardiovascular , or non-cardiovascular death compared with aspirin alone or short duration dual antiplatelet therapy.

GW26-e0268 Incidence and Predictors Of Prolonged Dual Antiplatelet Therapy Among Patients After Percutaneous Coronary Intervention

GW26-e0268 Incidence and Predictors Of Prolonged Dual Antiplatelet Therapy Among Patients After Percutaneous Coronary Intervention

TCT-556 One-year Outcome of a Prospective Trial Stopping Dual Antiplatelet Therapy at 3-Month after Everolimus-eluting Cobalt-chromium Stent Implantation: ShortT and OPtimal duration of Dual AntiPlatelet Therapy after everolimus-eluting cobalt-chromium stent (STOPDAPT) trial

Prolonged dual antiplatelet therapy (DAPT) after coronary stent implantation is associated with higher risk for bleeding. Second-generation drug-eluting stents (G2-DES), cobalt-chromium everolimus-eluting stent (CoCr-EES) in particular, are reported to have lower risk for stent thrombosis (ST)

Continuation of Dual-Antiplatelet Therapy Following Percutaneous Revascularization with a Drug-Eluting Stent: What Duration Is Optimal?

Dual-antiplatelet therapy (DAPT) is required after percutaneous coronary intervention with drug-eluting stents (DESs) to prevent thrombotic complications, particularly stent thrombosis (ST). However, there is still disagreement regarding the optimal duration of DAPT post-DES placement. Compared to bare metal stents, DESs are known to reduce restenosis and target vessel revascularization but may be more prone to late and very late ST due to delayed endothelialization. Several trials have suggested that longer (>12 months) DAPT reduces ischemic events but does so at the cost of increased bleeding. Other trials have demonstrated non-inferiority of shorter (3 to 6 months) DAPT compared to long-term DAPT, with fewer bleeding events. The clinical challenge is how to balance the reduced ischemic risk with increased bleeding associated with longer DAPT. Furthermore, ST is associated with multiple patient- and procedure-specific factors, thereby limiting a "one-size-fits-all" approach to determining optimal duration of DAPT. The evaluation of DAPT duration should therefore be tailored individually. We will review the data supporting current recommendations for DAPT and recent clinical trials comparing varying DAPT durations and discuss patient- and procedure-specific factors affecting the "optimal" DAPT duration.

Stents Eluting 6-Mercaptopurine Reduce Neointima Formation and Inflammation while Enhancing Strut Coverage in Rabbits.

BackgroundThe introduction of drug-eluting stents (DES) has dramatically reduced restenosis rates compared with bare metal stents, but in-stent thrombosis remains a safety concern, necessitating prolonged dual anti-platelet therapy. The drug 6-Mercaptopurine (6-MP) has been shown to have beneficial effects in a cell-specific fashion on smooth muscle cells (SMC), endothelial cells and macrophages. We generated and analyzed a novel bioresorbable polymer coated DES, releasing 6-MP into the vessel wall, to reduce restenosis by inhibiting SMC proliferation and decreasing inflammation, without negatively affecting endothelialization of the stent surface.MethodsStents spray-coated with a bioresorbable polymer containing 0, 30 or 300 μg 6-MP were implanted in the iliac arteries of 17 male New Zealand White rabbits. Animals were euthanized for stent harvest 1 week after implantation for evaluation of cellular stent coverage and after 4 weeks for morphometric analyses of the lesions.ResultsFour weeks after implantation, the high dose of 6-MP attenuated restenosis with 16% compared to controls. Reduced neointima formation could at least partly be explained by an almost 2-fold induction of the cell cycle inhibiting kinase p27Kip1. Additionally, inflammation score, the quantification of RAM11-positive cells in the vessel wall, was significantly reduced in the high dose group with 23% compared to the control group. Evaluation with scanning electron microscopy showed 6-MP did not inhibit strut coverage 1 week after implantation.ConclusionWe demonstrate that novel stents coated with a bioresorbable polymer coating eluting 6-MP inhibit restenosis and attenuate inflammation, while stimulating endothelial coverage. The 6-MP-eluting stents demonstrate that inhibition of restenosis without leaving uncovered metal is feasible, bringing stents without risk of late thrombosis one step closer to the patient.

Long-term dual antiplatelet therapy for secondary prevention of cardiovascular events in the subgroup of patients with previous myocardial infarction: a collaborative meta-analysis of randomized trials.

Recent trials have examined the effect of prolonged dual antiplatelet therapy (DAPT) in a variety of patient populations, with heterogeneous results regarding benefit and safety, specifically with regard to cardiovascular and non-cardiovascular mortality. We performed a meta-analysis of randomized trials comparing more than a year of DAPT with aspirin alone in high-risk patients with a history of prior myocardial infarction (MI). A total of 33 435 patients were followed over a mean 31 months among one trial of patients with prior MI (63.3% of total) and five trials with a subgroup of patients that presented with, or had a history of, a prior MI (36.7% of total). Extended DAPT decreased the risk of major adverse cardiovascular events compared with aspirin alone (6.4 vs. 7.5%; risk ratio, RR 0.78, 95% confidence intervals, CI, 0.67-0.90; P = 0.001) and reduced cardiovascular death (2.3 vs. 2.6%; RR 0.85, 95% CI 0.74-0.98; P = 0.03), with no increase in non-cardiovascular death (RR 1.03, 95% CI 0.86-1.23; P = 0.76). The resultant effect on all-cause mortality was an RR of 0.92 (95% CI 0.83-1.03; P = 0.13). Extended DAPT also reduced MI (RR 0.70, 95% CI 0.55-0.88; P = 0.003), stroke (RR 0.81, 95% CI 0.68-0.97; P = 0.02), and stent thrombosis (RR 0.50, 95% CI 0.28-0.89; P = 0.02). There was an increased risk of major bleeding (1.85 vs. 1.09%; RR 1.73, 95% CI 1.19-2.50; P = 0.004) but not fatal bleeding (0.14 vs. 0.17%; RR 0.91, 95% CI 0.53-1.58; P = 0.75). Compared with aspirin alone, DAPT beyond 1 year among stabilized high-risk patients with prior MI decreases ischaemic events, including significant reductions in the individual endpoints of cardiovascular death, recurrent MI, and stroke. Dual antiplatelet therapy beyond 1 year increases major bleeding, but not fatal bleeding or non-cardiovascular death.

Bioresorbable Stents: Is This Where We Are Headed?

Current drug-eluting stents (DES) have shown excellent safety and efficacy in various clinical settings. However, the presence of a permanent metallic scaffold remains an Achilles heel, with concerns for late stent thrombosis and the need for prolonged dual anti-platelet therapy. The bioresorbable vascular scaffold (BRS) has been termed the fourth revolution in interventional cardiology, with an ability to not only treat the coronary lesion, but also restore endothelial function after complete absorption. The absence of a permanent scaffold after months of implantation has the potential to overcome the shortcomings of current metallic DES and markedly impact interventional cardiology practice around the world. This review article focuses on the history, development and clinical studies on various BRS and attempts to predict how this technology could impact future cardiology practice.

Duration of dual antiplatelet therapy after drug-eluting stent implantation: Meta-analysis of large randomised controlled trials.

Patients receive dual antiplatelet therapy (DAPT) for 6–12 months after drug-eluting stents (DES) implantation. The efficacy and safety of prolonged DAPT has been questioned. Therefore, we performed a meta-analysis on randomised trials comparing different DAPT durations. Literature was searched on trials comparing different DAPT durations. For inclusion, reports must report frequency of cardiovascular and bleeding events. Ten trials were included. Compared to 12 months, DAPT beyond 12 months was associated with fewer myocardial infarctions (OR 0.58 95%CI: 0.40–0.84) and stent thrombosis (OR 0.35 95%CI: 0.20–0.62), but more major bleeds (OR 1.60 95%CI: 1.22–2.11) and all-cause (OR 1.30 95%CI: 1.02–1.66) mortality. There was no significant alteration in risk of stroke (OR 0.93 95%CI: 0.66–1.31) or cardiac (OR 1.12 95%CI: 0.73–1.71) mortality. Compared to less than 12 months DAPT, 12 months DAPT did not reduce risk of myocardial infarction, stent thrombosis, strokes, cardiac or all-cause mortality, but increased the risk of major bleeds (OR 1.60 95%CI: 1.22–2.11). DAPT beyond 12 months reduce risk of myocardial infarction and stent thrombosis, but there is substantial increase in major bleeding risk and all-cause mortality which need to be addressed. DAPT beyond 12 months does not appear to alter the risk of stroke.

Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease

ObjectivesPatients with chronic kidney disease (CKD) are at high risk of death or myocardial infarction (MI) after percutaneous coronary interventions (PCI). We assessed whether prolonged dual antiplatelet therapy beyond the...

Use of drug-eluting versus bare-metal stents after an acute coronary syndrome in Portugal: The EURHOBOP study

Introduction and ObjectivesThe interventional cardiologist chooses a specific stent type based on the risk-benefit profile for each case. In general, drug-eluting stents should be considered in all clinical conditions, except if there are concerns or contraindications for prolonged dual antiplatelet therapy. The aim of this work was to describe the use of bare-metal vs. drug-eluting stents in patients undergoing percutaneous coronary intervention (PCI) after an acute coronary syndrome in Portuguese hospitals, according to patients’ demographic and clinical characteristics and institutional characteristics. MethodsWithin the EURopean Hospital Benchmarking Processes (EURHOBOP) study, we retrospectively assessed 3009 consecutive patients in 10 Portuguese hospitals in 2009. Only patients with stents implanted during PCI (n=1194) were analyzed. ResultsA total of 425 patients (36%) received a bare-metal stent and 769 patients (64%) received a drug-eluting stent. A history of previous PCI, current non-ST-elevation myocardial infarction, anterior descending artery as the infarct-related artery and being initially admitted to a hospital with a catheterization laboratory were associated with drug-eluting stent implantation. Age under 45 or over 80, anemia and previous anticoagulation and/or atrial fibrillation were associated with bare-metal stent use. ConclusionsApproximately two-thirds of patients received drug-eluting stents, which were less frequently implanted in patients with ST-elevation myocardial infarction, aged over 80 years, female, with a previous history of stroke, anticoagulation and/or atrial fibrillation and anemia. Patients who had previously undergone PCI and those with the anterior descending artery as the infarct-related artery were more likely to receive a drug-eluting stent.

Use of drug-eluting versus bare-metal stents after an acute coronary syndrome in Portugal: The EURHOBOP study

Introduction and ObjectivesThe interventional cardiologist chooses a specific stent type based on the risk-benefit profile for each case. In general, drug-eluting stents should be considered in all clinical conditions, except if there are concerns or contraindications for prolonged dual antiplatelet therapy. The aim of this work was to describe the use of bare-metal vs. drug-eluting stents in patients undergoing percutaneous coronary intervention (PCI) after an acute coronary syndrome in Portuguese hospitals, according to patients’ demographic and clinical characteristics and institutional characteristics. MethodsWithin the EURopean Hospital Benchmarking Processes (EURHOBOP) study, we retrospectively assessed 3009 consecutive patients in 10 Portuguese hospitals in 2009. Only patients with stents implanted during PCI (n=1194) were analyzed. ResultsA total of 425 patients (36%) received a bare-metal stent and 769 patients (64%) received a drug-eluting stent. A history of previous PCI, current non-ST-elevation myocardial infarction, anterior descending artery as the infarct-related artery and being initially admitted to a hospital with a catheterization laboratory were associated with drug-eluting stent implantation. Age under 45 or over 80, anemia and previous anticoagulation and/or atrial fibrillation were associated with bare-metal stent use. ConclusionsApproximately two-thirds of patients received drug-eluting stents, which were less frequently implanted in patients with ST-elevation myocardial infarction, aged over 80 years, female, with a previous history of stroke, anticoagulation and/or atrial fibrillation and anemia. Patients who had previously undergone PCI and those with the anterior descending artery as the infarct-related artery were more likely to receive a drug-eluting stent.

Patient after myocardial infarction: how to reduce the risk of recurrent ischemic events?

The review article highlights concerns related to a low survival rate in patients after myocardial infarction (MI) and factors affecting it. The pivotal role is given to the issue of patient adherence to therapy after acute coronary events. The options to improve it as well as mechanisms to optimize medical therapy for patients after myocardial infarction, particularly the need for prolonged dual antiplatelet therapy (DAPT), have been identified. The rationale for changing the current guidelines for the management of patients with acute coronary syndromes (ACS) is based on the findings of the recently completed international clinical trial PE- GASUS-TIMI 54 with ticagrelor (Brilinta®), utilized as part of a DAPT regimen, that have demonstrated the efficacy and safety of DAPT prolongation after 12-month period in post-MI patients.

Are at least 12 months of dual antiplatelet therapy needed for all patients with drug-eluting stents? All patients with drug-eluting stents need at least 12 months of dual antiplatelet therapy.

Coronary artery disease (CAD) remains a principal source of morbidity and mortality among adults in both the developed world and the developing world.1 Despite important advances in medical therapy for CAD, revascularization is frequently necessary. Currently, nearly 2 million percutaneous coronary interventions (PCIs) are performed in the United States and Europe, and >90% of them entail the deployment of at least 1 coronary stent.2 The introduction of metallic coronary stents (bare metal stents [BMS]) 2 decades ago resulted in a significant reduction in the immediate and long-term complications of PCI, particularly dissections, abrupt vessel closure, and need for repeat target lesion or target vessel revascularization. Abrupt vessel closure was essentially eliminated by stents.3 The incidence of target lesion and target vessel revascularization was halved from ≈20% to 25% at 1 year to 10% to 15%. Stents became further refined a decade ago by the addition of eluting antiproliferative agents embedded in durable or resorbable biopolymers (drug-eluting stents [DES]).4–6 This innovation further reduced the need for target vessel or target lesion revascularization to the single-digit range. Response by Becker and Helmy on p 2009 The persisting weaknesses of coronary stents, the propensity to provoke stent thrombosis (ST) and late neoatherosclerosis, were not modified by the introduction of DES. In fact, a sentinel report in 2004 indicated that first-generation DES are prone to late (1–12 months) and very late (>12 months) ST because of their inherent delayed endothelialization.7 Intensive research into the causes and predictors of this phenomenon resulted in the current recommendations of the various professional societies to treat patients after DES implantation with 6 to 12 months of dual antiplatelet therapy (DAPT) consisting of aspirin and an ADP (P2Y12) receptor antagonist. This article reviews the evidence supporting the continuation of DAPT for …

Dual antiplatelet therapy in acute ischemic stroke.

Stroke recurrence is common in the early period after a cerebral ischemic event. Treatment with an antiplatelet agent is recommended to reduce recurrent stroke and death in patients with a non-cardioembolic ischemic stroke and transient ischemic attack. Compared to monotherapy, dual antiplatelet therapy has more robust inhibition of platelet activation but a higher risk of systemic bleeding and intracranial hemorrhage. Randomized controlled trials and meta-analyses suggest that short-term use of dual antiplatelet treatment initiated early after ischemic stroke and TIA reduces the risk of recurrent stroke and major vascular events without significantly increasing the hemorrhagic complication rates, particularly in those with large-vessel disease, while long-term dual antiplatelet treatment increases the risk of systemic and intracranial hemorrhage over time, offsetting any potential benefit. Until further data becomes available, clinicians should carefully assess this risk and benefit in each case and continually reevaluate the need for prolonged dual antiplatelet therapy.