Letter by Shah and Buch Regarding Article, “Prasugrel Plus Aspirin Beyond 12 Months Is Associated With Improved Outcomes After TAXUS Liberté Paclitaxel-Eluting Coronary Stent Placement”
Authors: Ashish H. Shah, Ashesh N. Buch
Journal: Circulation (2015)

We have read the article by Garratt et al 1 with interest.It appears that the patients in this study were of lower risk with low rates of major adverse cardiac and cerebrovascular events after the initial 12 months.Thirty months of dual-antiplatelet therapy (DAPT) demonstrated a reduction in major adverse cardiac and cerebrovascular events, mainly by reducing nonfatal myocardial infarction and stent thrombosis but with no mortality benefit.This was at the expense of excess bleeding.However, outcomes after percutaneous coronary intervention (PCI) are dependent on operator skills and experience, stent technology, use of intracoronary imaging, and tools to assess the hemodynamic significance of the lesion, in addition to the antithrombotic regime.The majority of mechanisms leading to stent thrombosis are procedure/stent related.The use of adjunctive intravascular ultrasound (IVUS) or optical coherence tomography optimizes PCI results.IVUS-or optical coherence tomography-guided PCIs not only reduced stent thrombosis, but also significantly improved all-cause mortality, myocardial infarction, and target vessel revascularization. 2,3Interestingly, in an all-comer study, IVUS findings resulted in larger stents (and thus larger minimal stent areas), and higher inflation pressures in 74% of PCIs.These IVUS-guided changes in interventional treatment highlight the inherent limitations of normally practiced angiography-guided PCI.At 1-year follow-up, the IVUS-guided group had significantly less stent thrombosis, myocardial infarction, or composite-adjusted major adverse cardiac and cerebrovascular events in comparison with angiography-guided PCI. 2 IVUS use was significantly limited in both groups of the present study.With regard to bleeding, the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) definition of bleeding severity was created to define thrombolysis-associated bleeding.Antiplatelet medication-induced bleeds usually do not fall into severe or fatal GUSTO categories.Bleeding is independently associated with mortality in patients undergoing PCI.Blood transfusion/erythropoietin therapy in patients who have undergone PCI is associated with higher mortality, not always from a cardiovascular cause. 4he stent concerned is a first-generation stent, more likely to have uncovered struts after 1 year of DAPT, an independent risk factor for late stent thrombosis.We are concerned some readers may inaccurately extrapolate results from this rigorously conducted study to current practice with third-generation drug-eluting stents.Hypothesis-generating data from small European studies suggesting <12 months of DAPT may be safe; longer duration of DAPT results in harm as a result of bleeding complications. 5Finally, more frequent use of IVUS or optical coherence tomography is likely to reduce stent thrombosis, restenosis, and subsequent associated acute coronary events, thereby also altering the risk/benefit ratio of prolonged DAPT in favor of shorter durations.