Duration of dual antiplatelet therapy after drug-eluting stent implantation: will we ever reach a consensus?

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This editorial refers to ‘ISAR-SAFE: a randomized, double-blind, placebo-controlled trial of 6 vs. 12 months of clopidogrel therapy after drug-eluting stenting’, by S. Schulz-Schüpke et al. , on page doi:10.1093/eurheartj/ehu523. ‘Well? Shall we go?’—‘Yes, let's go’. ‘They do not move.’Waiting for Godot, by Samuel Beckett, Combined treatment with aspirin and a P2Y12 inhibitor, the so-called dual antiplatelet therapy (DAPT) regimen, exerts protection against ischaemic myocardial recurrences via a double mechanism of action. First, it prevents sudden thrombotic occlusion of previously implanted stent(s) in the coronary arteries, thereby reducing the risk of stent thrombosis that occurs as a result of inflammation during healing.1,2 Since the vast majority of stent thrombosis cases are known to occur within the first weeks after stent implantation, an arbitrary 30 day to 6 weeks duration of DAPT has been investigated and a 30 day duration of therapy has become the standard of care approach after uncoated stent implantation. Secondly, DAPT has also been shown to mitigate the risk of subsequent myocardial infarction in patients not previously treated with coronary stents or arising from non-previously stented coronary segments.3,4 While the capability of DAPT to limit the progression of atherosclerosis per se has never been demonstrated, it remains likely—even if not proven—that DAPT protects the patient from the consequences of spontaneous coronary plaque rupture. The reasons why long-term prolongation of DAPT is debated, despite its unquestionable value, are two-fold. Long-term DAPT carries a time-dependent risk of major and clinically relevant bleeding complications, which affects morbidity and mortality at least as much as ischaemic recurrences.4–7 Moreover, the advent of drug-eluting stents (DES) has prompted attention …

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