Freedom from long DAPT signals the demise of the bare-metal stent

This editorial refers to ‘Biolimus-A9 polymer-free coated stent in high bleeding risk patients with acute coronary syndrome: a Leaders Free ACS substudy’, by C.K. Naber et al ., doi:10.1093/eurheartj/ehw203

Last year, the Leaders Free trial report was perceived in the interventional cardiology community as one of the most clinically relevant studies in recent history.1 The study clearly addressed a high bleeding risk (HBR) population including patients with 13 pre-defined clinical criteria at age ≥75 years or those with co-morbidities such as renal failure and oral anticoagulation therapy. The HBR patients undergoing percutaneous coronary intervention (PCI) also possess thrombo-ischaemic risks of stent thrombosis and future atherothrombotic events, which used to pose a clinical dilemma for physicians in the choice of stent type and antithrombotic regimens for HBR patients: a drug-eluting stent (DES) and relatively long dual antiplatelet therapy (DAPT) with additional bleeding risk and decreased ischaemic risk vs. bare-metal stent (BMS) and short DAPT with increased ischaemic (restenotic) risk and less additional bleeding risk.2 The Leaders Free study with 2466 patients provided a solution to the dilemma, demonstrating that the specific biolimus A9-eluting polymer-free stent (BA9-DCS) with a 1-month DAPT was safer and more efficacious than the BMS with the same DAPT regimen, with similar rates of bleeding events. Of note, the subgroup analysis showed that in patients presenting with acute coronary syndrome (ACS), the treatment effects of the two devices were different.

In this issue of the journal, Naber and colleagues provided further insights into the ACS population from the Leaders Free trials.3 In 659 HBR patients presenting with ACS at entry (BA9-DCS, 330; BM, 329), treatment with BA9-DCS and 1-month DAPT …