Coronary stent selection and optimal course of dual antiplatelet therapy in patients at high bleeding or thrombotic risk: Navigating between limited evidence and clinical concerns

Purpose of review Optimal duration of dual antiplatelet therapy (DAPT) after coronary revascularization, in particular after drug-eluting stent (DES) implantation, is a matter of ongoing debate. Recent findings First generation of DES, as compared with bare metal stents (BMS), reduce restenosis rates but increase very late stent thrombosis rates, thus requiring a prolonged course of DAPT. As a consequence, patients with high thrombotic and/or bleeding risk: have been systematically excluded from randomized trials comparing DES versus BMS; remain 'uncertain' DES candidates; should preferentially undergo BMS implantation at the time of percutaneous coronary intervention instead of DES. The Zotarolimus-eluting Endeavor Sprint Stent in Uncertain DES Candidates (ZEUS) trial is the first randomized study that demonstrated the superiority of the Zotarolimus-eluting Endeavor Sprint versus BMS in uncertain DES candidates who followed a personalized DAPT duration, which was tailored to patients's, not stent's, characteristics. Summary The results of the ZEUS trial may support a paradigm shift in our current understanding of the most proper use of DES in practice and should trigger further research in patients at high bleeding or thrombotic risk, who have been so far largely deprived of the potential benefit provided by DES.