Antiplatelet Therapy after Drug-Eluting Stents when Anticoagulation is Required: An International Poll Conducted on Twitter

Background: The optimal strategy for antiplatelet therapy in patients treated with drug-eluting stents (DES) who require anticoagulation remains an issue of uncertainty and controversy. We performed multivessel percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using DES in a patient with severe ischemic cardiomyopathy who was on anticoagulation for prior mechanical mitral and aortic valve replacements (MVR & AVR). Inspired by internal debate within our department regarding the appropriate course of dual antiplatelet therapy (DAPT), we sought opinions from a wide international audience using Twitter as a polling vehicle.
Case presentation: The patient is a 69 year old man on anticoagulation with St. Jude MVR and AVR, cardiomyopathy with ejection fraction ~10%, and worsening exertional dyspnea. He had prior bare metal stents in the left anterior descending and circumflex obtuse marginal coronary arteries with restenosis and CTO of both stented vessels. Repeat PCI was successfully performed on both vessels with placement of 3 DES. Before and after angiograms of the PCI-DES procedure were shown on a companion tweet.
Poll question: Given the need for anticoagulation, what DAPT duration is recommended? There were 4 response options: (1) DAPT ~1 month then clopidogrel only; (2) DAPT for 3-6 months; (3) DAPT for at least 1 year; (4) Clopidogrel only, no aspirin.
Poll results: The poll was posted on Twitter for 5 days from June 7-12, 2017. A total of 306 votes were submitted. The tweet with the final poll results are shown in the Figure. The results highlight the lack of consensus on management of DAPT in patients on anticoagulation as 3 different options were chosen by ~30% of the respondents (1 month, 3-6 months, and at least 12 months of DAPT). Fewer than 10% of respondents selected the option of clopidogrel alone without aspirin.
Conclusions: (1.) Twitter represents a promising vehicle for efficiently and easily obtaining opinions on medical practice and policy. (2.) Results of this Twitter poll reveal a wide divergence in opinion and lack of consensus on the management of DAPT in patients with DES on anticoagulation.