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DAPT Duration After DES

2015; Elsevier BV; Volume: 65; Issue: 11 Linguagem: Inglês

10.1016/j.jacc.2015.01.024

1558-3597

Roxana Mehran, Gennaro Giustino, Usman Baber,

Acute Myocardial Infarction Research

inhibitor and aspirin, remains unclear. Theneed for antiplatelet therapy post-DES implantationis predicated on mitigating risk for thromboticevents, which is highest in thefirst weeks to monthsafter percutaneous coronary intervention (PCI). Notsurprisingly, early cessation of DAPT has emerged asa strong, consistent, and independent risk factor forstent thrombosis (ST)(1,2).Thepotentialforasys-temic benefitofDAPTthatextendsbeyondthelocalstented segment to the remaining coronary vascula-ture, coupled with concerns for late ST with earlygeneration DES, provide a pathobiological rationaleforlonger(>1 year) DAPT durations. The unavoidablecorollary to extending the duration of antiplatelettherapy is increased bleeding, a complication thatmay have a more durable impact on long-term riskthan recurrent thrombosis(3). Indeed, bleeding con-cerns—in concert with the improved biocompatibilityand clinical safety of second-generation DES—haveled to clinical equipoise on the optimal DAPTduration after PCI on the basis of multiple random-ized comparisons. To date, 7 randomized controlledtrials (RCTs) (Figure 1) have reported similar is-chemic outcomes with 3- or 6-month DAPT durationcompared with longer DAPT regimens following DESimplantation. Conversely, with the exception of theDAPT study, 2 RCTs failed to demonstrate a reductionin ischemic events with DAPT prolongation beyond12 months(4–17).It is within this context that Palmerini et al.(18)report their findings from a patient-level pooledanalysis of 4 randomized trials (n¼ 8,180) comparingshorter (3- or 6-month) versus longer (12-month)DAPT durations after DES PCI in this issue of theJournal (18).Reflecting contemporary PCI practicepatterns, the most prevalent DES platforms inthe pooled cohort were everolimus-eluting andzotarolimus-eluting stents,respectively. The authorsfound nonsignificant differences in major adversecardiac events (MACE), defined as the composite ofcardiac death, myocardial infarction, and definite/probable ST, between groups at 12 months (hazardratio: 1.11; 95% confidence interval: 0.86 to 1.43;p ¼ 0.44). A shorter DAPT duration, however, yieldedsignificant reductions in bleeding (hazard ratio: 0.66;95% confidence interval: 0.46 to 0.94; p ¼ 0.03).Findings were concordant in several clinically re-levant subgroups (sex, age, diabetes, clinical pre-sentation, multivessel disease, and left anteriordescending artery as a target vessel) without evi-dence of statistical interaction for the primary MACEendpoint.In addition to the primary patient-level analysis,in which point estimates were stratified by trial,the authors also performed indirect comparisons be-tweenDAPTdurationsacrosstrialsusinganetworkapproach. Findings from these analyses were largely