Author + information
- Morten Lamberts, MD, PhD∗ (, )
- Gunnar H. Gislason, MD, PhD,
- Jonas Bjerring Olesen, MD, PhD,
- Søren Lund Kristensen, MD,
- Anne-Marie Schjerning Olsen, MD,
- Anders Mikkelsen, MB,
- Christine Benn Christensen, MD,
- Gregory Y.H. Lip, MD,
- Lars Køber, MD, DMSc,
- Christian Torp-Pedersen, MD, DMSc and
- Morten Lock Hansen, MD, PhD
- ↵∗Department of Cardiology–Post 635, Copenhagen University Hospital Gentofte, Niels Andersens Vej 65, 2900 Hellerup, Denmark
In response to our article (1), Dr. Aytürk and colleagues emphasize that the type of stent might affect the risk of stent thrombosis and consequently the need of prolonged dual antiplatelet therapy with aspirin and clopidogrel. We agree that the subject is complex, but physicians should acknowledge that current guidelines are based on Level of Evidence: C (2,3). In our opinion, there is no evidence to suggest that dual antiplatelet therapy is necessary in patients who receive oral anticoagulation, which itself offers coronary protection (4). Our registry-based study and 1 randomized study support the use of clopidogrel in addition to vitamin K antagonist (without aspirin) in patients with atrial fibrillation who are discharged after myocardial infarction or percutaneous coronary intervention (5). Although most stents implanted in recent years are drug-eluting stents, we acknowledge the important limitation of our data that no information on stent type was available. However, there is no indication that stent type should affect the risk of bleeding. Dr. Aytürk and colleagues wisely highlight that it is a multifaceted challenge when prescribing numerous antithrombotic drugs, and we would like to add to the ongoing and important discussion that bleeding risk merits serious attention. A bleeding event, per se, is associated with increased mortality, blood transfusion is associated with poorer prognosis, and minor bleedings could result in discontinuation of life-saving antithrombotic therapies (6). This is emphasized by the use of bleeding as a primary endpoint in many contemporary trials of antiplatelet use following stent implantation.
Until more randomized trial data are available, careful assessment of bleeding risk and recognizing current (although sparse) evidence is crucial when individualizing antithrombotic therapy in patients with atrial fibrillation who experience an acute coronary event with or without stent implantation (7). Due to bleeding complications, interventionists should carefully consider the need for a drug-eluting stent compared with a bare-metal stent and carefully consider the indication for stent implantation.
- American College of Cardiology Foundation
- Lamberts M.,
- Gislason G.H.,
- Olesen J.B.,
- et al.
- Steg P.G.,
- Huber K.,
- Andreotti F.,
- et al.