No Benefit to Prolonged Dual Antiplatelet Therapy After Drug-Eluting Stent Placement
Am Fam Physician. 2014 Oct 1;90(7):502.
Does prolonged dual antiplatelet therapy after the placement of a drug-eluting stent improve outcomes?
Prolonging dual antiplatelet therapy with aspirin plus clopidogrel (Plavix) for more than one year after the placement of a drug-eluting stent confers no clinical benefit. (Level of Evidence = 1b)
Current American College of Cardiology guidelines recommend dual antiplatelet therapy following drug-eluting stent placement for at least 12 months (J Am Coll Cardiol. 2011;57(19):1920–1959). Among patients who tolerate dual therapy for 12 months, is there any benefit to prolonged treatment for another two years? In this study, 5,045 patients received a drug-eluting stent and tolerated at least one year of dual antiplatelet therapy with aspirin and clopidogrel. None experienced a stroke, myocardial infarction, revascularization, or major bleeding episode during that period. They were then randomized to receive continued dual therapy or aspirin alone, receiving the drug(s) in an open-label fashion. However, outcomes were adjudicated by a committee that was masked to treatment assignment. The groups were balanced at the start of the study, with a mean age of 62 years; 69% of participants were men and 28% had diabetes mellitus. Approximately 80% were recruited after 12 to 18 months of successful dual antiplatelet therapy (the remainder after a longer period).
Compliance with aspirin was good throughout the trial, although compliance with clopidogrel in the group assigned to dual therapy declined to less than 80% after two years. There was no difference in the likelihood of any individual or combined cardiovascular or bleeding outcomes. Overall, the combination of cardiac death, myocardial infarction, stroke, stent thrombosis, or major bleeding occurred in 3.2% of the aspirin-only group and in 3.8% of the dual therapy group (hazard ratio = 0.84; 95% confidence interval, 0.62 to 1.14).
Study design: Randomized controlled trial (single-blinded)
Funding source: Foundation
Setting: Outpatient (specialty)
Reference: Lee CW, Ahn JM, Park DK, et al. Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: a randomized, controlled trial. Circulation. 2014; 129( 3): 304– 312.
POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.
For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.
To subscribe to a free podcast of these and other POEMs that appear in AFP,search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.
A collection of POEMs published in AFP is available at http://www.aafp.org/afp/poems.
Want to use this article elsewhere? Get Permissions
More in AFP
MOST RECENT ISSUE
Nov 15, 2017
Access the latest issue of American Family Physician