Poll Results: DAPT Duration Following PCI With Stent

In our most recent poll, we asked responders to select the minimal dual antiplatelet therapy (DAPT) duration for a 76-year-old patient with multiple bleeding risk factors presenting with a non-ST-segment elevation myocardial infarction (NSTEMI) and being treated with a durable polymer everolimus-eluting stent. After 447 responses, there was a trend towards longer DAPT duration. The most popular choice was 1 year (38.4%), followed by 6 months (28.4%), 3 months (21%) and finally 1 month (12.1%).

Poll Results: DAPT Duration Following PCI With Stent

After concerns for late stent thrombosis with first generation drug eluting stents drove clinicians to push for longer DAPT duration, advancements in stent design have led to encouraging results with shorter DAPT regimens. Thinner struts, biodegradable, and more biocompatible polymers as well as more liberal use of intracoronary imaging have led to faster endothelization and lower risk of stent thrombosis. Multiple recent studies have documented reduced bleeding risks associated with shorter DAPT regimens ranging from 1 to 6 months. In most studies the shorter DAPT strategy was noninferior to the standard of care of 1 year in terms of ischemic outcomes, however overall low numbers of thrombotic events and relative under representation of acute coronary syndrome (ACS) patients has continued to drive clinicians to adopt longer DAPT strategies and individuals with high thrombotic risk. This more conservative approach has prevailed in our poll with the most popular response being dual antiplatelet therapy for at least 1 year.

One of the most recent and larger studies in this area was the MASTER-DAPT study. After one month of DAPT, high bleeding risk patients undergoing percutaneous coronary intervention (PCI) were randomized to immediate interruption of DAPT or continuation for at least 2 additional months. The abbreviated strategy resulted in a similar number of ischemic events and lower bleeding risks. Almost 50% of the 4,434 participants had ACS at presentation. The treatment effect in net adverse clinical events was similar in this high-risk subgroup. In STOPDAPT-2 ACS however, a Japanese study enrolling over 4,000 ACS patients, 1 month of DAPT did not meet noninferiority when compared to the standard 12-month regimen. Although the abbreviated strategy led to a reduction in bleeding, there was a clear increase in ischemic events with a trend towards higher mortality. The diverging results of these two large studies with several methodological differences encourages an individualized risk versus benefits discussion.

Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS

Keywords: Platelet Aggregation Inhibitors, Drug-Eluting Stents, Everolimus, Percutaneous Coronary Intervention, Acute Coronary Syndrome, Non-ST Elevated Myocardial Infarction, Polymers, Standard of Care, Hemorrhage, Thrombosis, Risk Factors, Family Characteristics, Reference Standards

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