Dual Antiplatelet Therapy After Percutaneous Coronary Intervention

he optimal duration of aspirin plus a P2Y12 inhibitor for patients undergoing percutaneous coronary intervention (PCI) for stable ischemic heart disease is uncertain and continues to be debated.The benefit of preventing myocardial infarction (MI) and stent thrombosis (ST) is balanced against an increased risk of bleeding when continuing dual antiplatelet therapy (DAPT) beyond 12 months.These findings were demonstrated in the large DAPT study, 1 which showed that DAPT (aspirin combined with clopidogrel or prasugrel) beyond 12 months after PCI with drug-eluting stents (DES), significantly reduced the risks of ST and major adverse cardiovascular and cerebrovascular events but was linked to an increased risk of bleeding at 30 months compared with aspirin alone.Finally, rate of death from any cause was 2% in continued DAPT versus 1.5% in placebo (hazard ratio [HR], 1.36; 95% CI, 1.00-1.85;P=0.05).Many have concluded that the risks and benefits that DAPT duration beyond 1 year should be individualized based on patient's bleeding and ischemic risks. PREDICTING THE RISK OF ISCHEMIC AND BLEEDING EVENTSSeveral risk scores have been developed to assist with the identification of patients with greater benefits of a prolonged/extended (>12 months) period with DAPT, [2][3][4][5] including the DAPT score 2 derived from the DAPT study. 1 Briefly, the DAPT score 2 (http://ww6.daptstudy.org)ranges from -2 to 10 and assigns points as follows: 0 for patients <65 years; -1 for 65 to 74 years; -2 points for ≥75 years; 2 points for saphenous vein graft PCI and history of congestive heart failure or left ventricular ejection fraction <30%; and 1 point for current cigarette smoking or within a year, diabetes mellitus, MI at presentation, stent diameter <3 mm, prior PCI or MI, and paclitaxel-eluting stent.A DAPT score of ≥2 identifies subjects with a favorable benefit/risk ratio for prolonged DAPT, whereas a score of <2 identifies those with an unfavorable benefit/risk ratio (increased risk of bleeding).2 RAPID OVERVIEW TO THE GUIDELINESThe American 6 guidelines changed in 2016 for aspirin/clopidogrel for at least 6 months in PCI for stable ischemic heart disease as a class I recommendation, then dropping to class IIb recommendation for 12 months of DAPT.The European 7 guidelines agreed with the later but point out continuing with DAPT with clopidogrel for >6 months and ≤30 months may be considered (class IIb recommendation) unless

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