To the Editor: Dr Eisenstein and colleagues1 assessed the association between long-term clopidogrel use and clinical outcomes after drug-eluting stent (DES) implantation. The authors suggested that all patients with DES should continue to take clopidogrel for at least 12 months after intervention and possibly indefinitely. However, some methodological issues need to be considered.
Additional information about the primary outcome measures (death and myocardial infarction) is needed. Defining myocardial infarction according to the diagnosis of the patient's physician may be inaccurate. If available, further information on whether these infarcts were relatively large (Q-wave or associated with significant increases in creatine phosphokinase levels) or only caused minor myocardial damage (limited to troponin level elevation) will help understand if they can be considered as surrogate markers for late DES thrombosis.2 Conversely, while mortality was centrally adjudicated, separating deaths into cardiac and noncardiac causes would also be of interest.
Also, the explanation for the 0% rate of death and myocardial infarction in the DES group treated with clopidogrel (resulting in undefined hazard ratios) remains unclear. Despite the robust statistical analysis, this unusual finding could be the result of chance in a relatively small patient cohort (252 patients at 12 months, 230 patients at 24 months) rather than an indication of long-term clopidogrel benefit. Furthermore, at 24 months unadjusted and adjusted outcomes for both mortality and nonfatal myocardial infarction were significantly lower in the patients in the DES group receiving clopidogrel than the patients in the bare-metal stent group receiving clopidogrel. This is difficult to understand.
Defining the optimal duration of dual antiplatelet therapy remains a major challenge in the management of patients undergoing DES implantation.3 We agree with Eisenstein et al on the need for randomized controlled trials to address this problem. We believe that recommendations for long-term maintenance of a dual antiplatelet regimen for all patients treated with DES should not be made unless supported by such trials.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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