Dual Antiplatelet Therapy after Stent Placement – 2016 Guidelines

New ACC/AHA Guidelines came out in October 2016.  Below, from NEJM Journal Watch, are the key points:

Key Points

1. For most patients with coronary artery disease (CAD), decisions about the duration of DAPT require trade-offs between reduction in ischemic risk and increased bleeding risk. Clinicians should comprehensively assess both the ischemic- and bleeding-risk profiles of each patient, including newly available risk scoring.

2. In patients with stable IHD, DAPT is recommended for 6 to 12 months after DES implantation and ≥1 month after bare-metal stent (BMS) implantation (class I); longer therapy (>12 months) “may be reasonable” (class IIb). In patients with high risk for bleeding or overt bleeding, a shorter DAPT duration (3 months) after DES implantation may be reasonable (class IIb).

3. In ACS (both STEMI and NSTEACS), ≥12 months of DAPT is recommended (class I). Longer therapy may be reasonable (class IIb), particularly if the patient does not have overt bleeding or a high risk for it while on DAPT.

4. Lower-dose aspirin (75–100 mg) should be used in all DAPT regimens.

5. For ACS patients treated with DAPT after stenting, ticagrelor and prasugrel are reasonable P2Y12-inhibitor alternatives to clopidogrel (prasugrel only if the patient does not have a history of stroke or high bleeding risk). For medically treated patients, ticagrelor may be preferred to clopidogrel (class IIa).

6. In patients with stable CAD undergoing CABG, it may reasonable to start DAPT soon after surgery and continue it for 12 months to improve vein-graft patency (class IIb).

7. Elective noncardiac surgery should be delayed for 30 days after BMS implantation and, optimally, for 6 months after DES implantation (class I). If the surgery requires discontinuation of the P2Y12 inhibitor, aspirin should be continued (class I).


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