Key result
Long-term dual antiplatelet therapy beyond 1 month reduces ischemic endpoints after ACS or PCI but significantly increases major bleeding, leaving its overall long-term efficacy elusive.
Why the study?
Does long-term dual antiplatelet therapy improve ischemic outcomes compared to aspirin alone in patients with ACS or after PCI?
Does long-term dual antiplatelet therapy improve ischemic outcomes compared to aspirin alone in patients with ACS or after PCI?
While long-term DAPT reduces ischemic events post-ACS or PCI, it significantly increases major bleeding, making the optimal duration of therapy uncertain.
Caution advised on routine long-term DAPT extension after ACS/PCI due to bleeding; leaves open optimal duration and patient selection.
PURPOSE OF REVIEW: To evaluate whether long-term antiplatelet therapy may be effective and well tolerated. RECENT FINDINGS: Five important studies assessed the efficacy and safety of clopidogrel therapy in different settings. However, the problems concerning the duration of therapy are based substantially on the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) and Percutaneous Coronary Intervention (PCI)-CURE studies designed to test the hypothesis that the clopidogrel-aspirin combination is superior to aspirin alone when initiated early and continued for the long-term in the prevention of cardiovascular death, myocardial infarction, or stroke in patients with non-ST-segment elevation acute coronary syndrome (ACS). These studies suffer from some methodological flaws. Dual antiplatelet therapy (DAPT) beyond 1 month is beneficial in terms of prevention of ischemic endpoints after ACS or after PCI. However, the degree of benefit from long-term treatment post-PCI isolated from pretreatment is still impossible to determine. Similarly, whether the benefit is confined to the first few months after event/procedure or truly accrues over time is not fully established. Regarding safety, long-term DAPT is associated with a significant increase in major bleeding complications. Finally, the net clinical effect of aspirin monotherapy in these settings is unknown in the current era. Of the newer drugs, prasugrel and ticagrelor both showed favorable efficacy and safety profiles in their respective trials. SUMMARY: Despite many large studies, the efficacy of long-term DAPT remains elusive.
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Bolognese et al. (2011) conducted a review in Non-ST-segment elevation acute coronary syndrome (ACS) or post-PCI. Long-term dual antiplatelet therapy (DAPT) vs. Aspirin alone was evaluated on Cardiovascular death, myocardial infarction, or stroke. Long-term dual antiplatelet therapy beyond 1 month reduces ischemic endpoints after ACS or PCI but significantly increases major bleeding, leaving its overall long-term efficacy elusive.
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