12 Key Points from the Updated DAPT Guidelines for Patients with Coronary Artery Disease

• 12 Key Points from the Updated DAPT Guidelines for Patients with Coronary Artery Disease There has been a recent explosion of evidence evaluating different dual antiplatelet therapy (DAPT) in patients with ischemic heart disease. Some studies have attempted to take advantage of newer drug-eluting stents by exploring shorter durations (3 or 6 months), while others have explored extending DAPT out to several years after an acute coronary syndrome or myocardial infarction. In light of this new evidence, the American College of Cardiology/American Heart Association has recently published a document that provides contemporary, evidence-based recommendations for practicing clinicians. Below is a summary of the key points from this consensus document¹: The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y₁₂ inhibitor) in patients with coronary artery disease (CAD). Intensification of antiplatelet therapy, with the addition of a P2Y₁₂ inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference. Recommendations in the document apply specifically to duration of P2Y₁₂ inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD. Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75—100 mg). In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y₁₂ inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y₁₂ inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I). In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (eg, prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb). In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y₁₂ inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I). In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (eg, prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue DAPT in patients treated with coronary stent implantation.² In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y₁₂ inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y₁₂ inhibitor therapy (Class IIa). In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y₁₂ inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I). In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y₁₂ inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I). Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y₁₂ inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y₁₂ platelet receptor inhibitor be restarted as soon as possible after surgery (Class I). Reference: 1. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2016; doi:10.1016/j.jacc.2016.03.513. 2. Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention. JAMA. Published online March 29, 2016. doi:10.1001/jama.2016.3775.

There has been a recent explosion of evidence evaluating different dual antiplatelet therapy (DAPT) in patients with ischemic heart disease.

Some studies have attempted to take advantage of newer drug-eluting stents by exploring shorter durations (3 or 6 months), while others have explored extending DAPT out to several years after an acute coronary syndrome (ACS) or myocardial infarction.

In light of this new evidence, the American College of Cardiology/American Heart Association has recently published a document that provides contemporary, evidence-based recommendations for practicing clinicians.

Below is a summary of the key points from this consensus document¹:

• The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y₁₂ inhibitor) in patients with coronary artery disease (CAD).
• Intensification of antiplatelet therapy, with the addition of a P2Y₁₂ inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference.
• Recommendations in the document apply specifically to duration of P2Y₁₂ inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD.
• Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75—100 mg).
• In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y₁₂ inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y₁₂ inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).
• In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (eg, prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb).
• In patients with ACS (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y₁₂ inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).
• In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (eg, prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue DAPT in patients treated with coronary stent implantation.²
• In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y₁₂ inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y₁₂ inhibitor therapy (Class IIa).
• In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y₁₂ inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).
• In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y₁₂ inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I).
• Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y₁₂ inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y₁₂ platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).

References:

1. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2016; doi:10.1016/j.jacc.2016.03.513.

2. Yeh RW, Secemsky EA, Kereiakes DJ, et al. Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention. JAMA. Published online March 29, 2016. doi:10.1001/jama.2016.3775.