Duration of Dual Anti-Platelet Therapy Post-Percutaneous Intervention: Is There A Correct Amount of Time?
Dual antiplatelet therapy (DAPT) is effective in preventing in-stent thrombosis (IST) after placement of drug-eluting coronary stents (DES) and in attenuating risk of athero-thrombotic events, primarily myocardial infarction, among patients with advanced coronary atherosclerosis. However, all studies of DAPT demonstrate an increased risk of moderate or severe bleeding for the duration of therapy. The extent of benefit and risk with various periods of DAPT after DES placement has been evaluated in multiple observational studies and randomized clinical trials. Most studies indicate little or no important reduction of ischemic events but significant increases in bleeding with prolonged treatment. The Dual Antiplatelet Therapy Study was the only randomized trial sufficiently powered to assess IST as an individual endpoint, and this study found that continuing DAPT from 12 to 30months after DES placement provided important reductions in IST and a composite of adverse ischemic events. When all data are considered, a cogent argument can be made for using just 3 to 6months DAPT in patients treated with contemporary second generation DES when the goal of treatment is to avoid IST. Longer therapy should be recommended for patients treated with first generation DESs, for whom a persisting signal of IST risk is apparent, and for patients with low risk for bleeding who wish to minimize their risk of athero-thrombotic events, both related and unrelated to DES.
Center for Heart and Vascular Health, Christiana Care Health System, Wilmington, DE 19718. Electronic address: kgarrattmd@gmail.com.
Kirk N
KN
Garratt
D001792:Blood Platelets / Q000187:drug effects* / Q000378:metabolism; D003328:Coronary Thrombosis / Q000097:blood / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D054855:Drug-Eluting Stents; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D015539:Platelet Activation / Q000187:drug effects; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D010979:Platelet Function Tests; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D015398:Signal Transduction / Q000187:drug effects; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors
Antiplatelet therapy; Drug eluting coronary stent; In-stent thrombosis