Long-term antiplatelet therapy: from clinical trials to clinical application

Purpose of review: This review seeks to describe the emerging clinical trial data that informs clinical practice with regards to dual antiplatelet therapy. Recent findings: Recent evidence with vorapaxar has demonstrated an increase in bleeding events with only modest improvement in ischemic outcomes. Platelet function testing to inform clopidogrel dose selection has not shown improvement in clinical outcome. The impact of CYP2C19 loss-of-function alleles on clopidogrel effect may be more modest than initially reported, though an impact on stent thrombosis is evident. Among patients receiving current generation drug eluting stents, 6 months of dual antiplatelet therapy may provide similar ischemic outcomes with fewer bleeding events compared with 12 or 24 months of therapy. Novel anticoagulants entering clinical practice will also potentially influence the clinical decisions regarding the duration of dual antiplatelet therapy. Studies focussing on the discontinuation of aspirin as opposed to the P2Y12 inhibitor to reduce late bleeding risk should be considered. Summary: Evolving evidence and new therapies may enable shorter duration dual antiplatelet therapy.