Andreas Gruntzig performed the first PTCA on 16th September 1977, this was a 38 years old smoker who was alive and well till 2018, in the meantime he had a bare metal stent stent inserted in 2000 and then a drug eluting stent in 2014, he had had a left anterior descending coronary artery block to begin with.
The second PTCA was done also by Gruntzig on 18th October 1977 in a 44 year old male, who had blocks in his left main and right coronary arteries. The procedure this time was not successful and the patient needed a CABG operation in 1978, but all his grafts got blocked by 1997 and so he had a repeat CABG operation.
Following a drug eluting stent implantation it becomes necessary to begin blood thinners called antiplatelets. Two antiplatelets have used conventionally, that is a combination of aspirin and a P2Y12 inhibitor ( clopidogrel, ticagrelor, or prasugrel). This strategy is also called dual anti platelet therapy or DAPT. DAPT prevents stent thrombosis that can be catastrophic and fatal. Till recently DAPT was administered for at leat a year and then the P2Y12 inhibitor was stopped, but aspirin was continued for life. The problem was that DAPT or aspirin alone could serious bleeding complications.
Recently randomised trials comparing DAPT for 1-3 months versus DAPT for one year have shown that risks for death, heart attack or stroke are the same, but bleeding complications are significantly less with shortened DAPT duration.
A meta analysis published last year in the BMJ that included 6 randomised trials with almost 24,000 patients concluded the same, shorter DAPT was as good as one year of DAPT, with substantially less bleeding complications. It was also seen that women were especially at an advantage with the short DAPT, because they had significantly less mortality.
Now another randomised study from Korea in 3000 patients who were stented with second generation drug eluting stents (published late September 2022 in JAMA Cardiology) has shown that 3 months of DAPT has similar clinical risks as longer DAPT. Crucially, this study SMART CHOICE has the longest follow up of 3 years.
SMART CHOICE concludes that 3 months of DAPT is as good as 3 years of DAPT regarding death, myocardial infarction and stroke , but with almost 50% less severe bleeding complications. In this study as also in similar randomised rials the shorter DAPT regimen continues with a P2Y12 blocker while aspirin is dropped; this cohort is compared with 3 years of continuous DAPT.
The take home message is that 3 months of DAPT after a second generation drug eluting stent is enough, with continuation of clopidogrel, ticagrelor or prasugrel, but dropping aspirin.