Medical Research: What is the background for this study? What are the main findings?
Dr. Mauri: The Dual Antiplatelet Therapy (DAPT) Study, the largest randomized controlled trial to date comparing different durations of dual antiplatelet therapy (thienopyridine plus aspirin) after coronary stenting, found that patients who were free from major ischemic or bleeding events at 1 year after coronary stenting (either drug-eluting [DES] or bare metal [BMS]), and who were compliant with their antiplatelet therapy, experienced significant reductions in stent thrombosis and myocardial infarction (MI) but increases in moderate or severe bleeding when treated with 30 months of thienopyridine plus aspirin, as compared with 12 months. We analyzed these outcomes in a post hoc analysis of the subset of patients who received everolimus-eluting stents (EES) in the DAPT Study, because EES were the most frequently used stent in the study, and because data suggest that EES may have lower rates of stent thrombosis when compared with paclitaxel-eluting stents. We found that 30 months of dual antiplatelet therapy after coronary stenting (compared to 12 months) was associated with reduced rates of stent thrombosis and MI, no difference in a composite outcome of death, MI and stroke, and increased rates of moderate or severe bleeding.
As found in the primary analysis of the DAPT Study, 30 months of dual antiplatelet therapy was associated with increased all-cause mortality, largely due to increased non-cardiovascular mortality. Bleeding-related deaths accounted for a minority of these deaths, where as cancer-related deaths in patients with pre-existing cancer diagnoses accounted for the majority of the mortality difference.
Medical Research: What should clinicians and patients take away from your report?
Dr. Mauri: Most patients who, after coronary stenting, tolerate dual antiplatelet therapy for 12 months and are treatment compliant, including patients treated with EES, will benefit from prevention of myocardial infarction when treated beyond 12 months with dual antiplatelet therapy.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Mauri: Future studies should attempt to further refine clinicians’ ability to identify the patients for whom long-term dual antiplatelet therapy offers the greatest benefit while mitigating the risks, regardless of stent type.
Hermiller JB, Krucoff MW, Kereiakes DJ, et al. Benefits and Risks of Extended Dual Antiplatelet Therapy after Everolimus-Eluting Stents. JACC Cardiovasc Interv.
Online ahead of print October 12, 2015.
Laura Mauri, MD, MSc (2015). EE Stents for PCI: Benefits and Risks of Extending Dual Antiplatelet Therapy