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Controversies in Interventional Cardiology

Should dual antiplatelet therapy after drug-eluting stents be continued for more than 1 year?

Dual Antiplatelet Therapy After Drug-Eluting Stents Should Not Be Continued for More Than 1 Year and Preferably Indefinitely

Antonio Colombo, MD and Robert T. Gerber, MRCP, PhD

From the Catheterization Laboratory, San Raffaele Scientific Institute, Milan, Italy; and EMO-GVM Centro Cuore Columbus, Milan, Italy.

Correspondence to A. Colombo, EMO-GVM Centro Cuore Columbus, Via Buonarroti 48, 20145 Milan, Italy. E-mail colombo@emocolumbus.it

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Drug-eluting stents (DES) have significantly reduced the occurrence of in-stent restenosis with a coexistent reduction in revascularization compared with bare metal stents (BMS).^1–4 In September 2006, at the World Congress of Cardiology/European Society of Cardiology in Barcelona, a signal appeared of increased risk with DES more than BMS, namely that of late stent thrombosis.⁵ Although the concerns at that time were overemphasized and hyped⁶ by the media, when the smoke settled, more rigorous studies⁷ and standardized definitions of stent thrombosis⁸ demonstrated real ongoing concerns of late stent thrombosis.⁹ Potential mechanisms for stent thrombosis are described in Figure 1^10–15 and in the Table.^11,14–28 Subsequent studies then suggested possible benefits from prolonged (>6 months) dual antiplatelet therapy (DAT) after DES implantation in reduction in clinical events.^29,30 This prompted the Food and Drug Administration (FDA) to issue a guideline that patients should take DAT for up to 12 months after DES insertion based on indirect data and without a specific prospective study.³¹ We think the best way to address these issues is with the following Life Scenario.

View larger version (69K):   Figure 1. Proposed mechanisms leading to late and very late stent thrombosis. A and B, Late stent malapposition caused by persistent stent malapposition from underexpansion at the time of implantation.10 C and D, Late acquired stent malapposition caused by intrastent reabsorption of thrombus.11 E and F, Late acquired stent malapposition caused by vessel expansion due to remodeling (this last feature is specific for DES).11,12 G, New atherosclerotic lesion develops inside the stent leading to plaque . . . [Full Text of this Article]