Triple Antiplatelet Therapy May be Better for Longer Stent Lengths

Triple antiplatelet therapy with cilostazol results in lower in-stent restenosis (ISR) after drug-eluting stent (DES) implantation compared with dual therapy in patients with stent lengths greater than 40 mm. The findings provide a practical guide for use of triple antiplatelet therapy in routine clinical practice, according to a pooled analysis appearing online September 23, 2013, in the American Journal of Cardiology.

Researchers led by Seung-Jung Park, MD, PhD, of Asan Medical Center (Seoul, South Korea), pooled data from 1,399 patients enrolled in the dual (aspirin, clopidogrel) and triple (aspirin, clopidogrel, and cilostazol) therapy arms of the DECLARE-DIABETES and DECLARE -LONG, and DECLARE-LONG II trials. Different DES including sirolimus-eluting, paclitaxel-eluting, and zotarolimus-eluting stents were used prior to randomization to dual or triple therapy. 

On follow-up angiographic analysis, triple therapy compared with dual therapy reduced ISR (8.2% vs. 13.6%; RR 0.60; 95% CI 0.53-0.84; P = 0.003) and in-segment restenosis (9.0% vs. 15.7%; RR 0.58; 95% CI 0.53-0.65; P = 0.001).

On multivariate analysis, numerous factors predicted restenosis including cilostazol use, diabetes, and stent length (table 1).

Table 1. Predictors of Angiographic Restenosis


OR (95% CI)

P Value


0.49 (0.35-0.67)

< 0.001


0.12 (0.09-0.14)

< 0.001


1.99 (1.37-2.89)

< 0.001

Bifurcation Lesion

1.33 (1.17-1.52)

< 0.001

Stent Length

1.03 (1.02-1.04)

< 0.001

Postprocedural MLD

0.38 (0.17-0.87)


The threshold of stent length for predicting ISR in dual therapy patients was 39.5 mm, which had a sensitivity and specificity of 63.7% and 65.3%, respectively. Based on this, the patients with follow-up angiography (n = 1,173) were divided into 3 stent-length categories:

  • ≤ 20 mm
  • 20 to 40 mm
  • > 40 mm

ISR was lower with triple therapy in the group with stent length > 40 mm (12.4% vs. 22.1%; P = 0.008). The same was true for in-segment restenosis (13.8% vs. 23.9%; P = 0.008). In diabetic patients, triple therapy also showed reduced ISR in patients with stent length greater than 40 mm (15.4% vs. 32.3%; P = 0.003).

“From a practical point of view,” the authors note, “stent length is the most easily adoptable guideline in routine practice for cilostazol use after DES implantation.”

The authors add that such practice “could improve DES performance in complex coronary lesions,” especially since “. . . in the newer generation DES era, a long stent length remains a concern for restenosis and stent thrombosis.”

Furthermore, in the present study, they note that triple therapy showed improved efficacy even with a smaller postprocedural MLD. “Therefore, regardless of postprocedural MLD, patients with > 40-mm stent length are potentially good candidates for cilostazol addition immediately after coronary stenting,” they conclude.


Lee S-W, Lee J-Y, Ahn J-M, et al. Comparison of dual versus triple antiplatelet therapy after drug-eluting stent according to stent length (from the pooled analysis of DECLARE trials). Am J Cardiol. 2013;Epub ahead of print.

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  • The study was supported by a grant from the Korea Healthcare Technology Research and Development Project, Ministry of Health and Welfare, and the CardioVascular Research Foundation (Seoul, South Korea).
  • Dr. Park reports no relevant conflicts of interest.

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