Antiplatelet Therapy in Patients Receiving Percutaneous Coronary Intervention for Bifurcation Lesions

Antiplatelet therapy is crucial for patients after percutaneous coronary intervention (PCI), but there is limited high-quality evidence guiding the best strategy for those with bifurcation lesions. The antiplatelet strategy for bifurcation PCI requires balancing the patient's overall thrombotic and bleeding risks. Bifurcation lesions present a complex, high-thrombotic-risk milieu because the procedure often causes plaque disruption and forms an inevitable gap in the sealing of the stent, compounded by turbulent blood flow that promotes thrombosis. Factors like stent malapposition, underexpansion, and low/oscillatory shear stress also contribute to increased local thrombotic risk, making the optimal antiplatelet therapy for bifurcation PCI difficult to define. Previous observational registry data broadly suggested a prolonged duration of dual antiplatelet therapy (DAPT) may be safer than a shorter duration of DAPT in reducing major adverse clinical outcomes. However, the reliability of these findings is limited by the inherent flaws of registry data, including the retrospective study design, lack of clinical event adjudication, and lack of specific protocol of PCI or DAPT strategy. Moreover, specific lesions factors such as complex PCI and left main bifurcation lesions or patient factors such as the presence of high bleeding risk or clopidogrel resistance necessitate special consideration, which leads to a individualized DAPT strategy beyond registry generalizations. The future of care points toward precision medicine, necessitating dedicated, prospective randomized controlled trials with standardized procedures to establish clear, evidence-based recommendations.