Dual antiplatelet therapy duration after the placement of a drug-eluting stent: what are the data?

OPINION STATEMENT: The data supporting the immediate use of dual antiplatelet therapy (DAPT) post implantation of drug-eluting stents (DESs) is irrefutable. DAPT in this early period is necessary to prevent stent thrombosis during endothelialization of the stent, a process known to be delayed when DESs are placed. In addition, DAPT helps prevent thrombosis from plaque rupture that occurs outside of the initial stented area and/or at neo-atherosclerotic lesions within a previously coated stent. The ACC/AHA current guidelines (Levine et al. J Am Coll Cardiol. 58(24):e44-122, 2011) recommend 12 months of DAPT post DES implantation. As the result of several randomized clinical trials (Task Force on Myocardial Revascularization of the European Society of Cardio-Thoracic Surgery (EACTS) et al. Eur Heart J. 31(20):2501-55, 2010) showing the safety of a shorter duration of DAPT, the European Heart Society altered their recommendations to 6-12 months of DAPT post DES implantation. However, recent data from the DAPT trial (Mauri et al. N Engl J Med. 371(23):2156-66, 2014) clearly demonstrated less ischemic events with 30 months of DAPT. This trial and others have established that an increased DAPT duration increases bleeding risk which, in turn, increases subsequent morbidity and mortality. The current conundrum lies in defining the optimal time of DAPT post DES to adequately reduce ischemic events while minimizing bleeding risks. Future studies are required to better stratify patients into low and high risk for both ischemic and bleeding risks to assess whether shorter or longer courses of DAPT are the most appropriate for any specific patients. Until then, instead of a "one size fits all" approach to patients who receive DESs, the treating physician must consider both procedural and patient factors when deciding the optimal duration of DAPT for each patient.