Duration of antiplatelet therapy following intracoronary stenting: are changes needed?

This review addresses the question of whether established guidelines for the duration of dual-antiplatelet therapy (DAT) following intracoronary stenting need to be updated. Current recommendations for the optimal duration of DAT following percutaneous coronary intervention are limited by an inadequate evidence base. While the Percutaneous Coronary Intervention–Clopidogrel in Unstable angina to prevent Recurrent Events (PCI-CURE) and Clopidogrel for the Reduction of Events During Observation (CREDO) studies showed reductions in ischaemic events with prolongation of DAT out to 9–12 months, both the main CURE and CREDO studies showed an excess of major bleeding and are limited in generalizability by study design characteristics. Concerns regarding the rates of delayed acute stent thrombosis following drug-eluting stent (DES) implantation are integral to any debate on the optimal duration of DAT. The most reasonable conclusion from a number of divergent reports is that the evidence for an increased rate of stent thrombosis with DES therapy is conflicting. The Intracoronary Stenting and Antithrombotic Regimen: Safety And eFficacy of a 6-month DAT after drug-Eluting stenting (ISAR-SAFE) trial should help answer whether DAT should be routinely extended beyond 6 months post-DES implantation. Two other studies, ISAR-REBOUND and ISAR-CAUTION, are evaluating the effect of abrupt vs. tapered cessation of clopidogrel therapy on predefined in vitro and clinical endpoints and should shed further light on the existence and clinical significance of a rebound phenomenon following clopidogrel discontinuation.