Might Long-term Dual Antiplatelet Therapy Be Better?

Source: Elmariah S, et al. Lancet 2014;385:792-98

Short term (3-12 months) dual-antiplatelet therapy’s CVD risk reduction following coronary stenting is commonly accepted, and there are guidelines published to advise on the proper execution of such therapy. Ostensibly every major trial comparing DAT with monotherapy methods, however, reveals that dual-antiplatelet therapy’s reduction in risk of cardiovascular events is more than offset by the increased bleeding risks that the therapy creates. Moreover, in two large mega-trials that compared monotherapy with DAT in non-critical patients with preexisting cardiovascular disease, analysis failed to indicate any significant or beneficial reduction in stroke (in the MATCH trial) or coronary disease (in the CHARISMA trial); both tests, however, found a higher risk of bleeding during the DAT trial runs.

To evaluate these findings, Elmariah et al meta-analyzed randomized and controlled trials utilizing DAT post coronary stenting. They then compared results from short-term therapy or aspirin alone with longer-term treatments.

After the analysis of 14 clinical trials, Elmariah et al unearthed no evidence of longer duration treatment correlating with better results. While these results may seem disheartening, one investigative rationale for this study was the assumed confirmation of findings in the large Dual Antiplatelet Therapy Study, which concluded that non-cardiovascular death actually increased following the extension of dual-antiplatelet therapy past a year. Unfortunately, the meta-analysis neither confirmed nor refuted this finding.