Dual Antiplatelet Therapy for Coronary Artery Disease – 2016 Guideline Summary

From NEJM Journal Watch:

Update on Dual Antiplatelet Therapy for Patients with Coronary Artery Disease

Recommendations on the safety of a shorter duration of DAPT and individualized assessment of risks and benefits

Sponsoring Organizations: American College of Cardiology and American Heart Association, in collaboration with other professional societies

Background and Objective

This focused update accounts for 12 new studies on the optimal duration of dual antiplatelet therapy (DAPT) after coronary stenting, particularly later-generation drug-eluting stents (DES). The update affects parts of prior guidelines on percutaneous coronary intervention, coronary artery bypass grafting, stable ischemic heart disease (IHD), ST-segment elevation myocardial infarction (STEMI), non-ST-segment acute coronary syndromes (NSTEACS), and perioperative evaluation for noncardiac surgery. The class (strength) of recommendations is noted below in pertinent places; for levels of evidence, see the complete published update.

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).

COMMENT

Several prior guidelines on different patient groups with varied and earlier-generation stents had inconsistent recommendations on the duration of DAPT. This focused update attempts to harmonize recommendations for newer-generation devices across patient groups. In general, the new guidelines emphasize the safety of shorter DAPT regimens and the importance of individualizing the risks and benefits of DAPT and different antiplatelet agents based on the relative risks of ischemic events and bleeding.

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