Prof. Freek Verheugt,
The first statement: Ticagrelor is first choice in MI Dr. H Katus defended the pro position in this debate, but he referred only to comparison to clopidogrel which is an easy task because ticagrelor is far superior, and he didn’t mention prasugrel at all. Dr. Montalescot, who defended the contra position, specifically made comparisons between ticagrelor and prasugrel, where he pointed out that prasugrel seems superior to ticagrelor in the management of acute MI treated by primary PCI. Unfortunately, these were two different positions, since many believe that clopidogrel is an outdated antiplatelet strategy, although inexpensive and efficacious over placebo. So, the debate was not completely fair, and when hands were raised, most people supported the contra position. The second debate discussed the optimal duration of dual antiplatelet therapy (DAPT) in patients with a drug-eluting stent (DES), where many cardiologists believe that long term is mandatory in patients with a DES. The statement was: “6 months of DAPT is sufficient for DES”. Dr. M Valgimigli (Ferrara, IT) defended the pro position, with Dr. E Camenzind (Geneva, CH) against. Dr. M Valgimigli referred to his very well performed PRODIGY trial showing that 6 months of DAPT in over 2,000 patients was enough and longer treatment only leads to more major bleeding. He also referred to smaller trials of 6 vs 12 months of DAPT, or one year vs longer than one year. They all showed no benefit of longer duration DAPT and an increase in bleeding and also in major adverse cardiac events. Dr. Camenzind, however, put forward that not all DES are created equal. He defended the position that potent DES need much longer therapy than 6 months, whereas less potent DES may have shorter treatment duration. He also referred to the upcoming PROTECT study, where these two types of stents were compared head to head in a prospective, randomized design. In the rebuttal, Dr. Valgimigli admitted that the type of DES may influence the optimum treatment duration, as shown in his PRODIGY trial. When the audience was asked to vote, the majority supported the contra position, in that 6 months DAPT is probably insufficient for patients with a DES.
Controversies in antiplatelet therapy
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