Original title: Comparison of Dual Versus Triple Antiplatelet Therapy After Drug-Eluting Stent According to Stent Length (from the Pooled Analysis of DECLARE Trials). Reference: Seung-Whan Lee et al. Am J Cardiol 2013, article in press.

Cilostazol, an inhibitor of phosphodiesterase III , associated with aspirin and clopidogrel showed decrease angiographic restenosis both in conventional stents as well as in DES. DECLARE-DIABETES and DECLARE-LONG I and II studies yielded these results, however the question remained regarding which patients would benefit most and the absence of clear criteria that triple therapy did not come into daily practice.

This paper analyzed the angiographic follow up of the 1399 patients randomized to dual therapy (aspirin + clopidogrel) or triple therapy (aspirin + clopidogrel + cilostazol) in the 3 studies mentioned above. The primary objective of the study was to find stent restenosis indicators that justify cilostazol indication after angioplasty using DES. In the group with a triple scheme, in-stent restenosis was significantly reduced (8.2 % vs 13.6 % , RR 0.6 , CI 0.53 to 0.84, P = 0.003 ) and in- segment restenosis (9.0 % vs 15.7 %, RR 0.58 , CI 0.53 to 0.65 , p = 0.001). The cutoff in stent length from which benefit was significant with cilostazol was 39.5 mm. By dividing patients according to the length of stents implanted ( ≤ 20, 20 to 40 and ≥ 40 mm) we observed a significant difference in favor of the group receiving Cilostazol, -those who received ≥ 40 mm           (12.4 % vs 22.1 % , p = 0.008 ) . A similar trend was observed after dividing patients according to minimal luminal diameter ( ≤ 2.5, 2.5 to 3, and > 3 mm) with the greatest benefit in the smallest diameter ( p = 0.022 to ≤ 2.5 mm ) . 

Conclusion:

The triple scheme group (aspirin, clopidogrel, cilostazol) showed a significant reduction of restenosis in patients with more than 40 mm of stent length. Therefore, the use of the triple therapy may be readily employed in clinical practice after angioplasty using DES.

Editorial Comment

From a practical standpoint, the total length covered by stents is a simple guide for the indication of cilostazol after implantation of DES. Angiographic follow-up in these studies was set at 6 months (DECLARE-DIABETES y LONG I) and 8 months (DECLARE-LONG II), which is relatively premature and may be sub-estimated the restenosis. Drug-eluting stents used were mostly from 1st  generation so we must be cautious in extrapolating the results to the newer generations.

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