Dual Antiplatelet Therapy in Percutaneous Coronary Intervention

In 2016, dual antiplatelet therapy (DAPT) assumes its 20th anniversary since the publication of the first randomized clinical trial establishing the superiority of DAPT over anticoagulant therapy among patients undergoing percutaneous coronary intervention (PCI) (Figure). Because then, both antiplatelet therapy and PCI have undergone continued refinement. Clopidogrel substituted ticlopidine, and subsequently, more potent oral and intravenous P2Y 12 receptor inhibitors (prasugrel, ticagrelor, and cangrelor) entered the field of DAPT, whereas the advent of metallic drug-eluting stents (DES) and, more recently, completely bioresorbable scaffolds marked important milestones in the field of PCI. For several years, the duration of DAPT did not play a critical role in the pharmacological therapy after PCI. Indeed, DAPT was prescribed for 2 to 6 months after PCI in pivotal trials leading to the approval of the early-generation DES by the US Food and Drug Administration. It was only in the aftermath of increasing safety concerns related to the phenomenon of very late stent thrombosis after implantation of early-generation DES that prolongation of DAPT to 12 months was recommended by the American College of Cardiology Foundation/ American Heart Association/Society for Cardiac Angiography and Interventions guidelines. In the meantime, coronary stent technology rapidly evolved with the transition from earlyto newer generation DES, featuring lower drug loads, thinner stent struts, more biocompatible or biodegradable polymers, and eventually improved patient outcomes. Although newgeneration DES are currently recognized as default therapy in almost all lesion and patient subsets, the optimal duration of DAPT still remains the subject of debate.