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What is the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent implantation?

PURPOSE
Published evidence on varying durations of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent (DES) is reviewed.


SUMMARY
A systematic literature search identified 13 randomized controlled trials and eight meta-analyses evaluating patient outcomes of standard (12-month) versus shorter or longer courses of DAPT (aspirin and a P2Y12 inhibitor, usually clopidogrel) after PCI with DES implantation. Evaluated outcomes included cardiovascular (CV) events, stent thrombosis, bleeding events, and mortality. Overall, the available evidence indicates that DAPT for periods of 3-6 months was as effective as DAPT courses of 12 months or more in reducing rates of CV events and stent thrombosis and was associated with similar or lower rates of bleeding; however, the quality of that evidence was limited by methodological shortcomings, including open-label study designs and low overall event rates. Relative to 12-month DAPT, DAPT for longer periods (up to four years) was associated with decreased rates of CV events and stent thrombosis (the reduction in thrombosis risk was greatest in patients who received a first-generation DES) but also increased bleeding events; all-cause mortality appears to be similar or potentially higher with extended-duration DAPT.


CONCLUSION
DAPT for a period of 12 months should continue to be the standard recommendation after PCI with DES implantation. Routine use of shorter- or longer-duration DAPT should be discouraged; if such therapy is considered, prescribing decisions should be based on individual patient risk factors.