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Determining the optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention is a complex decision. Randomized controlled trials have shown that while shorter durations of DAPT may lower the risk of bleeding, longer durations of DAPT can reduce the risk of late stent thrombosis and ischemia-related events. In this review article, we will discuss the current guidelines, review contemporary trial data that have evaluated short and extended durations of DAPT, and address common clinical questions. Ultimately, the determination of the optimal duration of DAPT is an individualized decision that requires clinicians to assess each patient's risk for bleeding and recurrent ischemic events.

BACKGROUND: Practice patterns in anticoagulant strategies used during percutaneous coronary intervention (PCI) in the United States for patients with non-ST-segment-elevation myocardial infarction and the comparative outcomes between bivalirudin and unfractionated heparin (UFH) have not been well described.

METHODS AND RESULTS: Trends in anticoagulant use were examined among 553 562 PCIs performed by 9254 operators at 1538 hospitals for non-ST-segment-elevation myocardial infarction from 2009 to 2014 within the CathPCI Registry. To compare bivalirudin with UFH, propensity score matching and instrumental variable (IV) methods with operator preference for bivalirudin as the instrument were used. To determine whether differences in outcomes were because of differences in glycoprotein IIb/IIIa inhibitor (GPI) use, a test of mediation was performed using the IV. Outcomes were in-hospital bleeding and mortality. Bivalirudin use increased from 2009 to 2013 but declined during 2014. GPI use was 50.5% during UFH PCIs and 12.0% during bivalirudin PCIs. Before GPI adjustment, bleeding reductions with bivalirudin ranged from 2.04% (IV: 95% confidence interval [CI]: 1.81%, 2.27%) to 2.29% (propensity score: 95% CI: 2.14%, 2.44%) and mortality reductions ranged from 0.16% (IV: 95% CI: 0.03%, 0.28%) to 0.25% (propensity score: 95% CI: 0.17%, 0.33%). After GPI adjustment in the IV, more than half the bleeding reduction with bivalirudin was because of the lower use of GPIs (risk difference, -0.84%; 95% CI: -1.11%, -0.57%), and no survival benefit was apparent (risk difference, -0.10%; 95% CI: -0.24%, 0.05%). Bleeding reductions with bivalirudin were largest for transfemoral PCI (GPI-adjusted risk difference, -1.11%; 95% CI: -1.43%, -0.80%) and negligible for transradial PCI (GPI-adjusted risk difference, 0.09%; 95% CI: -0.32%, 0.50%).

CONCLUSIONS: In the largest comparative analysis of bivalirudin versus UFH for non-ST-segment-elevation myocardial infarction to date, bivalirudin was associated with lower in-hospital bleeding and mortality given current practices with respect to GPI use and access site. Bleeding differences were, in part, explained by the greater use of GPIs with UFH. Reductions in bleeding were largest among those undergoing transfemoral PCI, whereas no bleeding benefit was observed for those treated with transradial PCI.

This study examines the variability in color identification and perception of skin lesions in the context of background color and room illumination.

This study used People magazine to compare standards of beauty in 1990 with present-day standards.

Readmission after hospitalization for acute myocardial infarction (AMI) significantly contributes to preventable morbidity and health-care costs. Outcomes after AMI vary by sex but the relationship of sex to readmissions warrants further exploration. Using the 2013 Nationwide Readmissions Database, we identified patients with a principal discharge diagnosis of AMI and stratified all-cause 30-day readmissions by sex and age. Of 214,824 patients, 44% were 18 to 64 years of age, 56% were ≥65 years, and 28% and 45%, respectively, were female. For patients 18 to 64 years, the readmission rate was 14% for women and 10% for men (p <0.001). For patients ≥65 years, the readmission rate was 18% for women and 16% for men (p <0.001). After adjusting for co-morbidities, women had a significantly higher risk of 30-day readmission compared with men, an effect that was strongest in younger women (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.06 to 1.39, for ages 18 to 44; OR 1.13, 95% CI 1.07 to 1.18, for ages 45 to 64; OR 1.13, 95% CI 1.07 to 1.19, for ages 65 to 74, interaction p <0.001). The procedure rates during the index hospitalization were significantly lower for women. The most common readmission diagnoses were recurrent AMI, ischemic heart disease, and heart failure. Costs associated with readmissions after AMI totaled $447,506,740, of which $176,743,622 were attributed to readmissions of women. In conclusion, women are at higher risk of short-term readmission after an AMI hospitalization than men, particularly younger women. Sex-specific strategies to reduce these readmissions may be warranted.

OBJECTIVES: This study sought to determine whether patients with peripheral arterial disease (PAD) experience different reductions in ischemic event and increases in bleeding events with extended duration dual antiplatelet therapy versus those without PAD.

BACKGROUND: Patients with PAD have increased ischemic and bleeding risks after coronary stenting.

METHODS: The DAPT (Dual Antiplatelet Therapy) study randomized 11,648 patients free from ischemic and bleeding events 12 months after coronary stenting to continued thienopyridine plus aspirin therapy for an additional 18 months versus aspirin therapy alone. The effects of continued thienopyridine on myocardial infarction (MI) or stent thrombosis, major adverse cardiovascular and cerebrovascular events (death, MI, or stroke) and bleeding (GUSTO [Global Utilization of t-PA and Streptokinase for Occluded Coronary Arteries] moderate or severe) were assessed among those with versus without PAD.

RESULTS: Among 11,648 randomized patients, 649 (5.57%) had PAD. Between 12 and 30 months, randomized patients with PAD had higher rates of MI/stent thrombosis (6.03% vs. 2.92%; p < 0.001), major adverse cardiovascular and cerebrovascular events (11.65% vs. 4.62%; p < 0.001), and bleeding (4.86% vs. 1.74%; p < 0.001). Continued thienopyridine versus placebo was associated with consistent treatment effects for MI/stent thrombosis (with PAD, HR: 0.63; 95% CI: 0.32 to 1.22; without PAD, HR: 0.53; 95% CI: 0.42, 0.66; interaction p = 0.631), major adverse cardiovascular and cerebrovascular events (with PAD, HR: 1.06; 95% CI: 0.67 to 1.67; without PAD, HR: 0.70; 95% CI: 0.59 to 0.84; interaction p = 0.103), and bleeding (with PAD, HR, 1.82; 95% CI: 0.87 to 3.83; without PAD, HR: 1.66; 95% CI: 1.23 to 2.24; interaction p = 0.811).

CONCLUSIONS: Among patients undergoing coronary stenting, those with PAD have more ischemic and bleeding events versus those without PAD. Extended duration dual antiplatelet therapy is associated with consistent ischemic benefit and bleeding harm among patients with and without PAD.

IMPORTANCE: Early cardiovascular and bleeding events after coronary stenting are associated with high risk of morbidity and mortality.

OBJECTIVE: To assess the prognosis of cardiovascular and bleeding events occurring beyond 1 year after coronary stenting.

DESIGN, SETTING, AND PARTICIPANTS: This secondary analysis is derived from data from the Dual Antiplatelet Therapy (DAPT) Study, a multicenter trial involving 220 US and international clinical sites from 11 countries. The study dates were August 2009 to May 2014. Individuals who underwent coronary stenting and completed 12 months of thienopyridine plus aspirin therapy without ischemic or bleeding events remained on an aspirin regimen and were randomized to continued thienopyridine therapy vs placebo for 18 additional months. Individuals were then followed up for 3 additional months while receiving aspirin therapy alone. The analysis began in August 2015.

EXPOSURES: Ischemic events (myocardial infarction not related to stent thrombosis, stent thrombosis, and ischemic stroke) and bleeding events (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries [GUSTO] classification moderate or severe bleeding).

MAIN OUTCOMES AND MEASURES: Ischemic events (myocardial infarction not related to stent thrombosis, stent thrombosis, and ischemic stroke) and bleeding events (GUSTO classification moderate or severe bleeding). Death at 21 months after randomization (33 months after coronary stenting).

RESULTS: In total, 25 682 individuals older than 18 years with an indication for coronary stenting were enrolled, and 11 648 (mean age, 61.3 years; 25.1% female) were randomized. After randomization, 478 individuals (4.1%) had 502 ischemic events (306 with myocardial infarction, 113 with stent thrombosis, and 83 with ischemic stroke), and 232 individuals (2.0%) had 235 bleeding events (155 with moderate and 80 with severe bleeding). Among individuals with ischemic events, 52 (10.9%) died. The annualized mortality rate after an ischemic event was 27.2 (95% CI, 20.3-35.7) per 100 person-years. The cumulative incidence of death after an ischemic event among the total randomized study population was 0.5% (0.3% with myocardial infarction, 0.1% with stent thrombosis, and 0.1% with ischemic stroke). Among individuals with bleeding events, 41 (17.7%) died. The annualized mortality rate after a bleeding event was 21.5 (95% CI, 15.4-29.1) per 100 person-years. The cumulative incidence of death after a bleeding event among the total randomized study population was 0.3% (0.1% with moderate and 0.2% with severe bleeding).

CONCLUSIONS AND RELEVANCE: In patients treated with dual antiplatelet therapy for at least 1 year after coronary stenting, ischemic events were more frequent than bleeding events, and both events were associated with high risk of mortality.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00977938.