Updated guidelines for the use of dual antiplatelet therapy (DAPT) – aspirin plus a P2Y₁₂ inhibitor – in patients with coronary artery disease, were released March 29 by the ACC and the American Heart Association and published in the Journal of the American College of Cardiology.

The document updates recommendations on duration of DAPT across six previously published guidelines: the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (PCI), the 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft (CABG) Surgery, the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease (SIHD), the 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, the 2014 ACC/AHA Guideline for Non-ST-Elevation Acute Coronary Syndromes (ACS) and the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.

These recommendations are based on findings of recent studies of the length of time patients with coronary artery disease – specifically those with myocardial infarction and those receiving a stent – should be treated with DAPT. The new recommendations are also based on the use of newer stents that have a lower risk of clotting than some older stents. Studies examining shorter duration (three to six months) of DAPT compared with a standard 12 months of therapy in select, mostly lower-risk patients did not find any increased risk of stent thrombosis and, in some cases, found less bleeding. Other studies of prolonged or extended DAPT for an additional 18 or 36 months found a decrease in the risk of myocardial infarction and stent thrombosis at the expense of an increase in bleeding risk.

In the update, recommendations for DAPT generally consist of a Class I recommendation of “should be given” for a minimum time period of time (usually six to 12 months), and a Class IIb recommendation of “may be considered” for continuation beyond that time. Shorter duration of DAPT is recommended for patients at lower ischemic risk with high bleeding risk, whereas a longer duration of treatment may be reasonable for patients at higher ischemic risk with lower bleeding risk. These recommendations apply to newer-generation stents and, in general, only to those not treated with oral anticoagulant therapy. A dose of 81 mg daily (range 75 – 100 mg) is now recommended in patients treated with DAPT.

The document also addresses DAPT after CABG and issues regarding the timing of non-cardiac surgery in patients treated with PCI and DAPT. The writing committee notes that decisions about the timing of surgery and whether to discontinue DAPT after stent implantation should be individualized, and involve weighing the particular surgical procedure and the risks of delaying the procedure, the risks of ischemia and stent thrombosis, and the risk and consequences of bleeding. 

“Treatment with more intensive antiplatelet therapy and treatment for a longer duration of time with antiplatelet medicines in general involves a fundamental tradeoff between a decreased risk of future heart attack and an increased risk of bleeding complications,” explains Glenn N. Levine, MD, FACC, chair of the writing committee for the document.

To accompany the DAPT Update, the ACC has developed a DAPT After PCI Overview Tool that provides clinicians with guidance when treating SIHD and ACS patients undergoing PCI. The tool, the first in a new DAPT Update Toolkit, highlights that 81 mg of aspirin daily should be used in all SIHD and ACS patients as the gold standard. In addition to outlining the recommendations for these patients, the tool also utilizes the treatment algorithm for all clinicians to use when treating patients with SIHD and ACS who have undergone PCI.

Keywords: Acute Coronary Syndrome, Algorithms, Anticoagulants, Aspirin, Coronary Artery Bypass, Coronary Artery Disease, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Proliferating Cell Nuclear Antigen, Stents, Thrombosis

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