Current guidelines recommend 12 months of dual antiplatelet therapy (DAPT) following coronary stenting and in patients with acute coronary syndromes. However, there has been controversy regarding the duration of DAPT with recent studies demonstrating the benefits of prolonging DAPT beyond 12 months.
Which of the following patients is most likely to benefit most from prolonged DAPT?
Show Answer
The correct answer is: D. 66-year-old male patient with hyperlipidemia who received a DES to LAD artery for non ST-segment elevation MI 14 months ago, currently receiving aspirin and clopidogrel.
The DAPT Study (The Dual Antiplatelet Therapy Study) showed a decrease in major adverse cardiac and cerebrovascular events (MACCE) with prolonged DAPT beyond 12 months after coronary stenting in patients with no bleeding or recurrent MI in the first year.1 This is followed by PEGASUS-TIMI (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin) trail, which showed that DAPT with ticagrelor decreased MACCE in patients with prior MI (1-3 years old) and no history of stroke and recent bleeding.2 Yeh et al., in a post-hoc analysis of the DAPT Study, demonstrated that patients with MI had greater magnitude of benefit in terms of MACCE reduction compared with patients without MI.3 The CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance) trail showed no benefit from DAPT in patients with multiple comorbidities without symptomatic atherosclerotic vascular disease.4 However, across all the studies, patients treated with DAPT had increased bleeding. Selection of patients with a history of MI and low risk of bleeding is likely to yield highest net clinical benefit with prolonged DAPT. Although there are no current data to support preferential use of any particular P2Y12 antagonist, available data largely pertain to clopidogrel and ticagrelor.
References
Mauri L, Kereiakes DJ, Yeh RW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014;371:2155–66.
Flather M, Bakhai A, Perez de Arenaza D. Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction. N Engl J Med 2015;373:1274.
Yeh RW, Kereiakes DJ, Steg PG, et al. Benefits and Risks of Extended Duration Dual Antiplatelet Therapy After PCI in Patients With and Without Acute Myocardial Infarction. J Am Coll Cardiol 2015;65:2211-21.
Bhatt DL, Fox KA, Hacke W, et al. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006;354:1706-17.
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