Correspondence
The meta-analysis by De Luca et al.1 showed that the incidence of late (> 2 years) myocardial reinfarction and stent thrombosis is significantly higher in drug-eluting stents (DES) compared to bare-metal stents (BMS) in primary angioplasty despite the significant reduction in long-term target vessel revascularization associated with DES.
While the Comment section of the paper briefly mentions the role of more potent and prolonged dual anti-platelet therapy in countering these worrisome findings, the related Commentary2 does not. However, in our view the current practice of discontinuing dual anti-platelet therapy after 12 months in DES in most patients is the most likely explanation for the observed increase in late stent thrombosis and reinfarction incidence, in concordance with pathological evidence that even beyond 40 months, DES do not fully epithelialize3. In the De Luca et al.1 meta-analysis, the DES survival curves for both reinfarction and stent thrombosis start diverging from the BMS curves one year after stent implantation until year 6.
This also raises the most relevant question for practitioners: should we prolong dual anti-platelet therapy beyond 12 months after DES implantation? The Dual Antiplatelet Therapy Study (DAPT) is expected to give us a definitive answer to this question in 20144. For the time being, it seems that the argument to continue dual anti-platelet therapy beyond 12 months, which is fully in line with the current ACCF/AHA/SCAI recommendation5 to continue dual anti-platelet therapy for at least 12 months after DES implantation, has gained in strength.
Author contributions
IM drafted the first version of this correspondence article and IM and CAG have substantially revised it after discussion.
Competing interests
CAG is a member of the Asia-Pacific Advisory Board for Bayer Pharmaceuticals.
Grant information
We acknowledge funding from the National Institute for Health Research (NIHR) for CAG’s contribution to this article. The views and opinions expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health in England.
References
- 1.
De Luca G, Dirksen MT, Spaulding C, et al.:
Drug-Eluting vs Bare-Metal Stents in Primary Angioplasty: A Pooled Patient-Level Meta-analysis of Randomized Trials.
Arch Intern Med.
2012; 172(8): 611–21. PubMed Abstract
| Publisher Full Text
- 2.
Brophy JM:
Drug-Eluting Stents in ST-Segment Elevation Myocardial Infarction: Comment on “Drug-Eluting vs Bare-Metal Stents in Primary Angioplasty”.
Arch Intern Med.
2012; 172(8): 621–2. Publisher Full Text
- 3.
Joner M, Finn AV, Farb A, et al.:
Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk.
J Am Coll Cardiol.
2006; 48(1): 193–202. PubMed Abstract
| Publisher Full Text
- 4.
U.S. National Institutes of Health [cited 8 May 2012]. Reference Source
- 5.
Levine GN, Bates ER, Blankenship JC, et al.:
2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions.
J Am Coll Cardiol.
2011; 58(24): e44–122. Publisher Full Text
Comments on this article Comments (0)