DAPT after DES – What Should We Do Now?
Although the evidence apparently presents a chaotic and discrepant picture, some themes regarding our DAPT strategy for DES patients are manifest. First, that if DAPT is used for longer, the risk of ischaemic events, including ST, will be reduced. Second, that this reduction will be at the expense of increased bleeding. Third, strong circumstantial evidence suggests that if DAPT is used for more than a year, non-CV mortality is higher – perhaps because of the excess in important bleeding.
Taking these concepts together, it seems sensible to stick, for now, with a default of 12 months’ DAPT for most patients, pending further specific data.
DAPT after DES – What Do We Need to Know for the Future?
In order to make progress in this field, we need to address more precisely some unanswered questions. These are questions that cannot be answered in trials that recruit patients with a variety of elective and ACS presentations using different generations of stent and different DAPT constituents. We need answers to these questions via appropriately powered randomised trials:
Finally, what shines out of a forensic assessment of the current evidence about DAPT after DES is this: the concept that we can have wholesale strategies for APT for large groups of patients is fundamentally flawed. The real challenge is to develop personalised pathways of care that take into account individual risk of ischaemic events, bleeding and, probably, also their response to APT using point-of-care tests of platelet reactivity.26-27 It is time to discard our palpably inadequate “one-size- fits-all” approach and develop patient-specific strategies. Such an individualised approach might well eliminate many of the adverse effects we currently witness.