Conversations in Cardiology: Brief Question re: BMS-DES and DAPT

From: Mort Kern, MD
Sent: Wednesday, March 06, 2013 11:30 PM

Dear Colleagues,

Dr. Lloyd Klein of Chicago writes, "I was wondering if you had ever polled the list of experts as to how long after BMS and DES they continue dual anti-platelet therapy. And a second question: if a patient needs a surgical procedure and the stent is being placed as a consequence to pre op evaluation showing ischemia, how soon after the PCI is the surgery done, and do you modify the selection of stents for this reason?

In brief:
1. How long do you continue DAPT after BMS?
2. How long do you continue DAPT after DES?
3.  If a surgery is needed and preop stent placed for ischemia,  when do you do surgery?
4.  Do you change your selection of stent knowning surgery is needed?

As usual, my great appreciation for sharing your opinion and again no obligations to participate.

Mort

Morton Kern, MD
University of California, Irvine Medical Center

From: Bernhard Meier, MD
Sent: Thursday, March 07, 2013 5:11 AM

Here is my non-evidence based approach, banking on 36 years of experience in the field.

I have not used a BMS for more than 10 years except for rare cases where no DES would fit anatomically or technically.

I stopped using double antiplatelet therapy with the advent of ticagrelor and prasugrel (my first choice because of once daily dose). Acetylsalicylic acid is no longer of the party with my patients.

DES always needed less antiaggregants early on. The data were always there but overlooked, now  with new DES they are very conspicuous. The polymer must be antithrombogenic while they are naked. First generation DES had admittedly more thrombosis risk late but new DES do not have that blemish any longer while even emphasizing their reduced risk early on over BMS (including during surgery).

So life in this respect is quite simple for me and my patients.

Bernie

Bernhard Meier, MD, FACC, FESC
Bern University Hospital

From: Kirk Garratt, M.D
Sent: Mar 7, 2013, at 8:47 AM

You’ve certainly been at the forefront on many things, Bernie.  I’ve heard that the newest Resolute DES received labeling approval in Europe for just 1 month DAPT:  is that correct?  I know there will be a presentation on 1 month DAPT in these stents at ACC next week.

Kirk N. Garratt MSc MD
Lenox Hill Heart and Vascular Institute of NY

From: Mitchell Krucoff, M.D
Sent: Thursday, March 07, 2013 9:25 AM

we should always be careful to scrutinize the basis for labeling, in both EU and USA.

remember what led to 1 year DAPT after DES was a consensus, not a guideline or even data-based.  

reduced requirements for xience and resolute (1-3 months) are all based on interruption of dapt, not routine cessation of dapt, data!

mwk

Mitchell W. Krucoff MD, FACC, FAHA, FSCAI
Duke University Medical Center

From: Gregg W. Stone, MD
Sent: Thursday, March 07, 2013 10:28 AM

Mitch is clearly right about this. Except all the premature DAPT discontinuation studies have so far showed no harm, and in fact even showed safety by prevention of bleeding. Nonetheless, we need the large-scale DAPT trial to inform us whether DAPT has any long-term on-target (i.e. stent thrombosis) and off-target (i.e. ACS) benefits without substantial safety issues. And other adequately powered trials of early DAPT discontinuation are currently ongoing or planned by all the major sponsors. 

Gregg

Gregg W. Stone, MD
New York Presbyterian Hospital/ Columbia University Medical Center

From: Kirk Garratt, M.D.
Sent: Thuursday, Mar 7, 2013 at 7:45 AM

Great comments.  The notion of very early DAPT discontinuation could have huge clinical impact (and make several drug companies unhappy), so it’s regrettable that the DAPT Trial won’t inform us on very early discontinuation (other than non-protocol withdrawals).

Kirk N. Garratt MSc MD
Lenox Hill Heart and Vascular Institute of NY