Purpose of review: To evaluate whether long-term antiplatelet therapy may be effective and well tolerated.
Recent findings: Five important studies assessed the efficacy and safety of clopidogrel therapy in different settings. However, the problems concerning the duration of therapy are based substantially on the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) and Percutaneous Coronary Intervention (PCI)-CURE studies designed to test the hypothesis that the clopidogrel-aspirin combination is superior to aspirin alone when initiated early and continued for the long-term in the prevention of cardiovascular death, myocardial infarction, or stroke in patients with non-ST-segment elevation acute coronary syndrome (ACS). These studies suffer from some methodological flaws. Dual antiplatelet therapy (DAPT) beyond 1 month is beneficial in terms of prevention of ischemic endpoints after ACS or after PCI. However, the degree of benefit from long-term treatment post-PCI isolated from pretreatment is still impossible to determine. Similarly, whether the benefit is confined to the first few months after event/procedure or truly accrues over time is not fully established. Regarding safety, long-term DAPT is associated with a significant increase in major bleeding complications. Finally, the net clinical effect of aspirin monotherapy in these settings is unknown in the current era. Of the newer drugs, prasugrel and ticagrelor both showed favorable efficacy and safety profiles in their respective trials.
Summary: Despite many large studies, the efficacy of long-term DAPT remains elusive.