Duration of Dual Antiplatelet Therapy After Coronary Stenting

Montalescot G, Brieger D, Dalby AJ, Park SJ, Mehran R.
Duration of Dual Antiplatelet Therapy After Coronary Stenting: A Review of the Evidence. J Am Coll Cardiol 2015;66:832-847.

The following are 10 points to remember from this review about the duration of dual antiplatelet therapy (DAPT) after coronary stenting in 2015:

  1. Currently, DAPT refers to the addition of a P2Y12 platelet receptor inhibitor (either a thienopyridine [clopidogrel or prasugrel], or the cyclopentyl-triazolopyrimidine, ticagrelor) to aspirin, aiming to reduce stent thrombosis after coronary stent implantation and prevent coronary atherothrombotic events at sites outside the stented segment.
  2. The complex interaction between the efficacy and safety of DAPT has prompted a series of investigations to determine which duration of DAPT optimizes the risk-benefit equation.
  3. Based on current evidence, duration of mandatory DAPT can range from 3 to 12 months, and depends on the patient’s clinical presentation, overall risk profile, lesion complexity, and the type of stent implanted. Beyond the mandatory period, DAPT prolongation has to be carefully considered.
  4. Two randomized studies and a few registries have suggested that 3 months of DAPT was possible with the latest drug-eluting stent generation.
  5. Extension of DAPT confers protection against stent-related and nonstent-related atherothrombotic events. However, the antithrombotic benefit may be counterbalanced by an increased bleeding risk, which impacts on morbidity and mortality and cannot be disregarded.
  6. Prolongation of DAPT beyond 1 year after DES implantation is possible. The strategy of using DAPT to reinforce secondary prevention is more sensible in patients at high ischemic risk, although the benefit was observed across almost all subgroups.
  7. Long-term DAPT reduces stent-related and nonstent-related thrombotic events at the cost of more bleeding complications, translating into no survival advantage.
  8. After a short mandatory period of 3-6 months, DAPT should be tailored over time on the basis of the clinical profile, the type of stent, the patient’s tolerance, comorbidities, and preference.
  9. At this stage, clinicians are advised to individualize decisions regarding the type and duration of DAPT in stented patients.
  10. Finally, a very important and often underestimated aspect of post-procedural percutaneous coronary intervention management is optimal medical therapy (OMT). OMT is a broad term that incorporates the control of lifestyle risk factors (weight loss, smoking cessation, dietary regimen, and exercise) and specific pharmacotherapy to control arterial hypertension, hyperlipidemia, and chronic hyperglycemia, and should be instituted in every patient.

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