Individualization of dual antiplatelet therapy duration after drug-eluting stent implantation: paradigm and reality

This editorial refers to ‘Should duration of dual antiplatelet therapy depend on type and/or potency of implanted stent? A pre-specified analysis from the PROlonging Dual antiplatelet treatment after Grading stent-induced Intimal hyperplasia studY (PRODIGY)’[†][1], by M. Valgimigli et al. , on page 909 The use of drug-eluting stents (DES) results in a dramatic reduction in restenosis and represents one of the major advances in interventional cardiology. Yet, a reduction in death and myocardial infarction could not be shown with these devices; instead there were concerns about an excess of late thrombotic events compared with bare metal stents (BMS).1 The key underlying pathophysiological mechanism was suggested to be delayed arterial healing after DES implantation.2 Several non-randomized studies found controversial results regarding the duration of dual antiplatelet therapy (DAPT) and its impact on the risk of stent thrombosis.3,4 Since different stent platforms show different vessel healing5 and antiproliferative properties, it has been suggested that those with less antiproliferative properties (i.e. reduced efficacy) offer improved vascular healing (i.e. safety).6 The importance of DAPT in the early post-procedural period is well evidenced.7 However, the optimal time point when the benefit of preventing ischaemic events is outweighed by an increased bleeding risk has not been reliably defined. This controversy is also reflected in the different recommendations for DAPT duration after DES implantation by the guidelines committees on both sides of the Atlantic.8,9 Yet despite being much debated in the DES era, the problem of defining the optimal duration of DAPT for patients with coronary artery disease is … [1]: #fn-2