No One-Size-Fits-All

Antiplatelet therapy with aspirin is a cornerstone of secondary prevention in coronary artery disease (CAD), mainly to prevent recurrent ischemic events. Specifically, it is recommended to use aspirin indefinitely in all revascularized patients.1,2 This “secondary preventive effect” of antiplatelet therapy is even more important in patients at high risk, such as those with acute coronary syndromes. In these patients, dual antiplatelet therapy (DAPT) with clopidogrel in addition to aspirin should be given for 9–12 months, as evidenced by the Percutaneous Coronary Intervention subgroup of the Clopidogrel in Unstable angina to prevent Recurrent Events trial (PCI-CURE).3 However, in the large Clopidogrel for High Atherotrombotic Risk and Ischemic Stabilization, Management and Avoidance (CHARISMA) trial, DAPT was not superior to aspirin monotherapy.4 Thus, there is no firm trial evidence for a possible longer-term benefit of DAPT in CAD in high-risk patients with or without revascularization.Articles see p 505 and p 514More recently, DAPT has been used successfully to prevent stent thrombosis (ST) after coronary stent implantation. According to the AHA/ACC guidelines for coronary intervention,1 DAPT is recommended for 1 month in patients with bare-metal stents without acute coronary syndromes and for 12 months in patients with bare-metal stents with acute coronary syndromes and for all patients with drug-eluting stents (DES). However, the 2010 European guidelines on myocardial revascularization state that convincing evidence for the duration of DAPT after DES implantation exists only up to 6 months,2 keeping in mind that the 12-month time period was suggested primarily for safety reasons. Main concerns against a DAPT duration ≥6 months after DES are the following: increased bleeding rates and costs; occurrence of ST irrespective of DAPT beyond 6 months;5,6 “premature” interruption of DAPT in case of unplanned surgery; and decreased ST rates beyond …