Twelve Months Dual Antiplatelet Therapy after Drug-eluting Stents - Too Long, too Short or Just Right?

Dual Antiplatelet Therapy (DAPT) remains a cornerstone in the secondary prevention of coronary artery disease. Further, in contemporary practice, a period of DAPT is considered a mandatory requirement after intracoronary stents to prevent stent thrombosis (ST), a complication associated with heart attack and a mortality rate of up to 40 %. In current clinical practice, the default strategy in most centres is 12 months' DAPT followed by aspirin alone for life. However, the optimal duration of DAPT, particularly given the rapid iterative turnover of drug-eluting stents (DES) is the subject of discrepant evidence and clinical uncertainty. In particular, the 12-month regimen is based upon relatively weak evidence. A series of fairly small randomised trials, not powered to look specifically at ST as an endpoint, have recently indicated that there is no apparent disadvantage to shorter versus longer duration DAPT (including several trials of >12 months versus 12 months) when looking at various composite clinical endpoints. By contrast, the 9,961 patient DAPT trial, published in the New England Journal of Medicine at the end of 2014, demonstrated clinical outcome benefit, including a significantly lower rate of ST as a predefined primary endpoint, in DES patients randomised to 30 months' DAPT compared to stopping at 12 months. Here, the authors to assess the data, including the most recent meta-analyses, in an attempt to answer the question: DAPT after DES...12 months, longer or shorter?