Two Years After DAPT Trial, We're Still Debating

Michelle L. O'Donoghue, MD, MPH


October 19, 2016

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Hi. This is Dr Michelle O'Donoghue, reporting for Medscape. I was interested to read in JAMA Cardiology a series of prospective pieces debating the value of continuing dual antiplatelet therapy (DAPT) beyond 1 year after stenting.[1,2,3,4] It made me pause and wonder how we are ever going to actually resolve this debate.

I remember, prior to the publication of the DAPT trial that came out in the New England Journal of Medicine a couple years ago,[5] that there was a lot of debate at that time about whether there was enough convincing evidence from smaller randomized clinical trials that we might be able to get away with shorter durations of DAPT, at least in lower-risk patients. However, at that time, the consensus was, "Let's wait for the larger DAPT trial that's really going to provide us with the definitive results.'

But it's intriguing that after the publication of DAPT, there seems to be as much controversy on this topic as there was before. The results of DAPT showed us that continuing DAPT beyond 1 year significantly reduces cardiovascular events, including cardiovascular death, myocardial infarction, or stroke, and has a fairly profound reduction on stent thrombosis risk. But, not surprisingly, given that it was a placebo-controlled trial, it did increase the risk for major bleeding.

So, where are we going to come down on this topic? The guidelines have now allowed some flexibility, saying that it is reasonable to continue DAPT beyond 1 year in your higher-risk patients.[6] Of course, we're supposed to factor in the risk for bleeding and whether we think that that patient is suitable for longer-term DAPT.

We do have DAPT scores that have been developed to try to help assess both bleeding and ischemic risk, but are we still using those practically at this point? Is it more intuition that is helping to guide those decisions? And if we are just using our intuition to help pick which patients continue DAPT, is that really the right approach? Perhaps, but perhaps not.

It's also interesting that there seems to be quite a continental divide on this subject. I hear from my European colleagues that shorter durations of DAPT have been more universally embraced, whereas in North America, physicians tend to continue DAPT beyond 1 year.

I'm interested to hear your thoughts on this subject. It's a touchy one and people continue to debate it strongly on both sides of the line. I think it's tough. We have a reduction in cardiovascular events but an increased risk for bleeding. When it comes to the stronger antiplatelet drugs like prasugrel and ticagrelor, the guidelines have endorsed using them preferentially over older P2Y12 inhibitors like clopidogrel, despite the fact that they increase the risk for bleeding.

It's interesting that perhaps we've more universally embraced that strategy early after acute coronary syndrome with these stronger antiplatelet drugs, but that there remains debate beyond 1 year. So I'd love to hear where you fall on each side of the line and continue the discussion.

Reporting for Medscape on, this is Dr Michelle O'Donoghue.


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