Long-Term Secondary Prevention After High-Risk Stenting

Dual antiplatelet therapy (DAPT), the combination of aspirin and an inhibitor of the platelet P2Y12 receptor, is the foundation to prevent acute stent thrombosis (ST), the sudden thrombotic coronary occlusion that can lead to myocardial infarction or death in one third of patients.1 The appropriate duration of DAPT in patients who have received coronary stents is an important dilemma for interventional cardiologists and a daily concern. We have entered the third decade of coronary stent implantation, the dominant strategy for myocardial revascularization, without clear guidance on the duration of DAPT.2 Professional guidelines are not entirely consistent, recommending extension of DAPT up to 6 months after implantation of a second-generation drug-eluting stent (DES)3 or at least 12 months after implantation of a DES unless patients are at high risk for bleeding.4 None of these guidelines recommend long-term or lifelong DAPT. The current discrepancies may reflect either a different interpretation of the data by experts of the guideline committees or, more likely, an active area of clinical investigation in which early certainties about DAPT duration after coronary stenting are being challenged.Article see p 62So far, 12 randomized, interruption studies investigating various durations of DAPT, whether short, intermediate, or prolonged (≥2 years), have been conducted (Figure). All published randomized trials to date (n>19 000) indicate no benefit of extended DAPT with clopidogrel beyond 6 or 12 months after DES but harm,5 suggesting that the pendulum has swung back toward short DAPT duration (Table). The lack of power for important safety end points such as death, major bleeding, or ST is a common limitation of these trials. In addition, 1 randomized trial6 and 2 registries7,8 suggest that DAPT duration should be device specific, further adding complexity to …