Optimal duration of clopidogrel therapy: the shorter the longer?

This editorial refers to ‘Clinical impact of extended dual antiplatelet therapy after percutaneous coronary interventions in the drug-eluting stent era: a meta-analysis of randomized trials’, by S. Cassese et al. , doi:10.1093/eurheartj/ehs318 After the initial enthusiasm for drug-eluting stents (DES) based on their impressive reduction in restenosis, there was increasing concern about an increased and sustained risk for stent thrombosis ( Figure 1 ). Consequently, the recommendation for the duration of dual antiplatelet therapy (DAPT) was gradually extended from initially 3 months for sirolimus-eluting stents (SES) and 6 months for paclitaxel-eluting stents (PES) to currently at least 12 months for all DES. This recommendation is reinforced by most cardiovascular societies including the American College of Cardiology (ACC)/American Heart Association (AHA) and the National Institute for Health and Clinical Excellence (NICE) in the UK, while the European ESC guidelines recommend at least 6–12 months of DAPT for DES,1 and at least 12 months after an acute coronary syndrome (ACS) regardless of stent type.2 Not uncommonly, cardiologists recommend indefinite DAPT if the patient has no bleeding complications during the first 12 months. The need for long-term DAPT is costly and remains the Achilles' heel of DES; furthermore, the excess risk for stent thrombosis associated with DES is a matter of an ongoing controversy. Ongoing improvements in second- and third-generation DES drug coatings as well as other factors such as stent design may have all changed the rates of stent thrombosis. Newer generation stents have shown impressively low stent thrombosis rates and, therefore, the excessive bleeding risk of DAPT has to be reconsidered.3,4 The newest generation everolimus-eluting stents (EES) have revealed very low stent thrombosis rates,3 and, in Europe, Abbott's Xience V and Xience PRIME stents have recently received the CE mark with 3 months DAPT, further adding to the …