Short- versus long-term duration of dual antiplatelet therapy after coronary stenting: A randomized multicentre trial
Valgimigli M, Campo G, Monti M, Vranckx P, Percoco G, Tumscitz C, Castriota F, Colombo F, Tebaldi M, Fucà G, Kubbajeh M, Cangiano E, Minarelli M, Scalone A, Cavazza C, Frangione A, Borghesi M, Marchesini J, Parrinello G, Ferrari R.
Circulation 2012, Mar 21 [Epub ahead of print].
For EPCCS reviewed and commented by dr Frans Rutten, Utrecht The Netherlands
Based on previous studies, guidelines advocated to treat patients after stenting with dual antiplatelet therapy for at least one year. This large trial, including patients receiving a bare metal stent as well as different types of coated stents shows that 6 months of dual antiplatelet therapy would be sufficient. Bearing in mind the risk of haemorrhage, and health care economics, clopidogrel (and possibly the newer antiplatelets) should be stopped after 6 months while continuing aspirin.
The optimal duration of dual antiplatelet therapy and the risk-benefit ratio for long-term dual antiplatelet therapy after coronary stenting remain poorly defined. In this study the authors evaluated the impact of up to 6 versus 24 month duration of dual antiplatelet therapy in a broad patient population receiving a balanced proportion of Food and Drug Administration-approved drug-eluting or bare metal stents.
Methods and Results:
In total 2,013 patients were randomly assigned to receive bare metal, zotarolimus-eluting, paclitaxel-eluting or everolimus-eluting stent implantation. At 30 days, patients in each stent group were randomly allocated to receive up to 6 or 24 months clopidogrel therapy on top of aspirin. The primary endpoint was a composite of death from any cause, myocardial infarction or cerebrovascular accident. The cumulative risk of the primary outcome at 2 years was 10.1% with the 24-month dual antiplatelet therapy, as compared to 10.0% with the 6-month dual antiplatelet therapy (hazard ratio 0.98; 95%CI 0.74 to 1.29; p=0.91). The individual risks of death, myocardial infarction, cerebrovascular accident or stent thrombosis did not differ between the study groups. However, there was a consistent greater risk of haemorrhage in the 24-month clopidogrel group according to all pre-specified bleeding definitions including the recently proposed Bleeding Academic Research Consortium classification.
A 24-month clopidogrel therapy in patients who had received a balanced mixture of drug-eluting or bare-metal stents was as effective as a 6-month clopidogrel regimen in reducing the composite of all-cause death, myocardial infarction or cerebrovascular accident.