ESC focused update on dual antiplatelet therapy in coronary artery disease published today

August 26, 2017

Barcelona, Spain - Aug. 26, 2017: The first ESC Focused Update on Dual Antiplatelet Therapy in Coronary Artery Disease is published online today in European Heart Journal,1 and on the ESC website.2 The document was developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).

"Dual antiplatelet therapy (DAPT) is a controversial topic on which a lot of conflicting evidence has been generated," said Dr Marco Valgimigli (Switzerland), Task Force Chairperson. "This has led to a great deal of uncertainty in the medical community, particularly regarding the optimal duration of DAPT after coronary stenting."3

DAPT is among the most intensively investigated treatments in the field of cardiovascular medicine. Research has focused on the refinement of P2Y1,2 inhibition strategies and optimal treatment duration. This document provides recommendations on DAPT in patients with coronary artery disease (CAD).

Chapters are devoted to DAPT and percutaneous coronary intervention (PCI), DAPT and cardiac surgery, DAPT for patients with medical managed acute coronary syndrome (ACS), DAPT for patients with an indication for oral anticoagulation, elective non-cardiac surgery in patients on DAPT, and DAPT in specific populations including women, patients with diabetes mellitus, and patients who develop bleeding during treatment.

DAPT reduces the risk of acute to very late stent thrombosis, and after myocardial infarction (MI) or PCI it reduces the rate of spontaneous MI. The risk of bleeding in patients on DAPT is proportionally related to its duration. The benefits of prolonged DAPT, especially on mortality, depend on prior cardiovascular history (such as prior ACS/MI versus stable CAD). The document recommends the use of prediction models to estimate on-DAPT bleeding risk, and advocates an individualised approach based on ischaemic versus bleeding risks.

The most contentious issue was the need for a prolonged DAPT regimen (beyond 12 months) in ACS patients treated with PCI. "This is a setting in which one needs to think twice about how to maximise the benefits over the risks," said Dr Valgimigli. "The most novel and important message here is that DAPT is a regimen to treat a patient, not the previously implanted stent. This is crucial and the community needs to adapt to this new treatment paradigm."

The Task Force recommends that for ACS patients, the default DAPT duration should be 12 months, irrespective of the revascularisation strategy (medical therapy, PCI or coronary artery bypass graft surgery [CABG]). Six months of DAPT should be considered in patients at high bleeding risk. Therapy longer than 12 months may be considered in ACS patients who have tolerated DAPT without a bleeding complication.

The document emphasises that the need for a short DAPT regimen should no longer justify the use of bare metal stents instead of newer generation drug-eluting stents (DES). DAPT duration should be guided by an assessment of the individual patient's ischaemic versus bleeding risks and not by the stent type.

Irrespective of the type of metallic stent implanted, the duration of DAPT in stable CAD patients treated with PCI should be one to six months depending on the bleeding risk. A longer DAPT duration may be considered in patients whose ischaemic risk is greater than the risk of bleeding.

There is insufficient data to recommend DAPT in stable CAD patients treated with CABG.

The addition of DAPT to oral anticoagulation therapy increases the risk of bleeding complications by two- to three-fold. The indication for oral anticoagulation should be reassessed and treatment continued only if there is a compelling indication such as atrial fibrillation, a mechanical heart valve, or recent history of recurrent deep venous thrombosis or pulmonary embolism. The duration of triple therapy (DAPT plus oral anticoagulation) should be limited to six months or omitted after hospital discharge depending on the ischaemic and bleeding risks.

Clopidogrel is recommended as the default P2Y1,2 inhibitor in patients with stable CAD treated with PCI, patients with an indication for oral anticoagulation, and ACS patients in whom ticagrelor or prasugrel are contraindicated. Ticagrelor or prasugrel is recommended for ACS patients unless there are drug-specific contraindications. The decision on when to initiate a P2Y1,2 inhibitor depends on both the specific drug and the specific disease (stable CAD versus ACS).

A similar type and duration of DAPT therapy are recommended for male and female patients, and for patients with and without diabetes mellitus.

Dr Valgimigli said: "The Task Force advocates a personalised medicine approach where each treatment and its duration is individualised as much as possible. The document highlights who should, and should not, receive long-term treatment, while at the same time outlining how to maximise the expected benefits over the risks."

A unique aspect of this Focused Update is the accompanying Clinical Cases companion document in which the Task Force shows how to use the recommendations in real life challenging cases submitted by the medical community.
-end-


European Society of Cardiology

Related Coronary Artery Disease Articles from Brightsurf:

Researchers use multi-ancestry comparison to refine risk factors for coronary artery disease
An international group led by researchers from the RIKEN Center for Integrative Medical Sciences have used a combination of genome-wide association analysis--or GWAS--and a trans-ancestry comparison of different GWAS studies, to come up with a more accurate predictor of coronary artery disease based on genetic factors.

Oral radiography can reveal chronic coronary artery disease
A study found a link between carotid artery calcification observable in radiographs and coronary artery disease as well as several oral infections.

A new strategy to counter insulin damage in coronary artery disease
By studying blood vessel tissue from 674 patients, a research team has discovered how insulin contributes to the dysfunction of blood vessels in atherosclerosis, one of the most common chronic health conditions worldwide.

3D fusion imaging improves coronary artery disease diagnosis
A new technique that combines CT and MRI can bolster coronary artery disease diagnosis and help to define appropriate treatment for patients suffering from the disease, according to a new study.

Associations between vaspin levels and coronary artery disease
In a new publication from Cardiovascular Innovations and Applications; DOI https://doi.org/10.15212/CVIA.2019.0565, Lutfu Askin, Okan Tanriverdi, Hakan Tibilli and Serdar Turkmen from the Department of Cardiology, Adiyaman Education and Research Hospital, Adiyaman, Turkey consider associations between vaspin levels and coronary artery disease.

Waist size, not body mass index, may be more predictive of coronary artery disease
For years, women have been told that weight gain could lead to heart disease.

Women with coronary artery wall thickness at risk for heart disease
The thickness of the coronary artery wall as measured by MRI is an independent marker for heart disease in women, according to a new study.

SPIE journal reports advances in use of 3D models in assessing coronary artery disease
In an article published in SPIE's Journal of Medical Imaging (JMI), researchers announce critical advances in the use of 3D-printed coronary phantoms with diagnostic software, further developing a non-invasive diagnostic method for Coronary Artery Disease (CAD) risk assessment.

E-cigarettes linked to heart attacks, coronary artery disease and depression
Concerns about the addictive nature of e-cigarettes -- now used by an estimated 1 out of 20 Americans -- may only be part of the evolving public health story surrounding their use, according to data being presented at the American College of Cardiology's 68th Annual Scientific Session.

Is guideline-recommended therapy for coronary artery disease more likely in Medicare Advantage?
Medicare Advantage is Medicare's managed-care alternative to traditional fee-for-service Medicare.

Read More: Coronary Artery Disease News and Coronary Artery Disease Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.