Physicians' Academy for Cardiovascular Education

Better outcome with longer dual antiplatelet treatment in real-life ACS population

Varenhorst et al., Eur Heart J. Oct 2013 - Eur Heart J. 2013 Oct 11. [Epub ahead of print]


Duration of dual antiplatelet treatment with clopidogrel and aspirin in patients with acute coronary syndrome.

 
Varenhorst C, Jensevik K, Jernberg T et al.
Eur Heart J. 2013 Oct 11. [Epub ahead of print]
 

Background

Dual antiplatelet treatment (DAPT) with aspirin and P2Y12 receptor inhibitor is given to patients with acute coronary syndrome (ACS), whether they are treated invasively or non-invasively. Guidelines recommend treatment of 9-12 months after ACS and up to 12 months after drug-eluting stents placement, although no trial has supported extended DAPT.
Recent trials have suggested no net clinical benefit of treatment with DAPT longer than 6-12 months after drug-eluting stent implantation. These trials had, however, limited power and did not specifically include ACS patients [1-3].
Premature discontinuation of clopidogrel is known to induce stent thrombosis [4-6]. On the other hand, recent trials with newer generation drug-eluting stents have suggested low event rates despite a relatively short DAPT duration [3,7]. Register studies show no evidence of a reduction of ischaemic adverse events when continuing clopidogrel treatment for longer than six months [8].
The Swedish Websystem for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) is a national register of all patients hospitalized for ACS in Sweden [9].The SWEDEHEART register was used to evaluate the effect of different DAPT durations (depending on dispensed clopidogrel tablets) with clopidogrel and aspirin on clinical outcome in ACS patients.
 

Main results

 

Conclusion

This first large outcome analysis of varying DAPT durations in patients discharged with ACS, shows that DAPT of >3 months is associated with a statistically significantly lower incidence of death/stroke or re-infarction than DAPT of 3 months. Bleeding risk was higher at DAPT for longer than 3 months than for 3 months, but the overall incidence was low.
 

References

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