Tools for Practice

#72 Dual Antiplatelet Therapy Following Drug-Eluting Stent Placement: 3 Months, 1 Year or Forever?

In patients with coronary artery disease who have drug-eluting stent (DES) placement, how long should we prescribe dual antiplatelet therapy (DAPT), such as aspirin plus clopidogrel?

Current evidence shows small reductions in cardiovascular events balanced by a small increase in major bleed and mortality for DAPT duration >12 months. Guidelines recommend >12 months for ACS and >6 months for elective DES placement, with ½ these durations if major bleed occurs. Patient preferences and values should guide DAPT duration.

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Multiple meta-analyses of 11 Randomized Controlled Trials (RCTs), 33,051 patients comparing DAPT durations of 3-48 months following DES placement. 
  • One meta-analysis1 (10 RCTs) comparing “longer” versus “shorter” DAPTstatistically significant:  
    • Decreased risk of: 
      • Myocardial infarction (MI)-0.8%/year, Number Needed to Treat (NNT)=125. 
    • Increased risk of: 
      • All-cause mortality: +0.2%/year, Number Needed to Harm (NNH)=500. 
      • Major bleed: +0.6%/year, NNH=167. 
    • Other meta-analyses2-4 found: 
      • 3-6 versus 12 months:  
        • Death,2,3 MI/stent thrombosis:2-4 No difference. 
        • Major bleed: No difference2 or reduction,3,4 NNT=250-385. 
      • 18-48 versus 6-12 months: 
        • Death: No difference2,3 or higher risk.4 
        • MI/stent thrombosis: Reduction.2-4 
        • Major bleed: Increase.2-4
  • 2016 American DAPT guidelines5 recommend: 
    • Acute coronary syndrome (ACS) +/- stent placement: DAPT >12 months. 
      • Consider stopping at six months if high bleed risk or develop overt bleed. 
    • DES placement for stable coronary artery disease: DAPT >6 months. 
      • At six months, re-assess & consider for longer if low bleed risk. 
      • Stop after three months if develop bleed. 
  • Reduction of “very late” stent thrombosis (one year after DES placement)the primary goal of prolonged DAPT, rarely occurs with newer DES: 
    • 0.8% with 2nd generation DES versus 3% with paclitaxel-eluting stent (1st generation stent no longer used in practice).6 
    • In-hospital mortality is <4%7 (previously overestimated as 20-45%8). 
  • Preliminary clinical predictions rules9,10 (such as the DAPT Score) describe factors to consider shorter/longer duration: 
    • Longer (increase MI)ACS/MI at presentation, prior MI/revascularization, heart failure or ejection fraction <30%, diabetes and certain stent/procedural factors. 
    • Shorter (increased bleed): Agelow/high BMI, anemia, and anticoagulation. 
updated july 20 2016 by ricky

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  • G. Michael Allan MD CCFP
  • Ricky D. Turgeon BSc(Pharm) ACPR PharmD

1. Spencer FA, Prasad M, Vandvik PO, et al. Ann Intern Med. 2015; 163:118-26.

2. Bittl JA, Baber U, Bradley SM, et al. Circulation. 2016; 134(10):e156-78.

3. Giustino G, Baber U, Sartori S, et al. J Am Coll Cardiol. 2015; 65:1298-310.

4. Navarese EP, Andreotti F, Schulze V, et al. BMJ. 2015; 350:h1618.

5. Levine GN, Bates ER, Brindis RG, et al. J Am Coll Cardiol. 2016; 68(10):1082-115.

6. Mauri L, Kereiakes DJ, Yeh RW, et al. N Engl J Med. 2014; 371:2155-66.

7. Kohn CG, Kluger J, Azeem M, et al. PLoS ONE. 2013; 8:e77330.

8. Grines CL, Bonow RO, Casey DE. Circulation. 2007; 115:813-8.

9. Yeh RW, Secemsky EA, Kerelakes DJ, et al. JAMA. 2016; 315:1735-49.

10. Baber U, Mehran R, Giustino G, et al. J Am Coll Cardiol. 2016; 67:2224-34.

Authors do not have any conflicts of interest to declare.