ACC/AHA vs. ESC Dual Antiplatelet Therapy Guidelines
What are the common domains, consistent messages, and differences in recommended management strategies for dual antiplatelet therapy (DAPT) across the Atlantic?
The investigators reviewed and compared the American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) updates for DAPT to delineate common domains, consistent messages, and differences in recommended management strategies across the Atlantic. Common themes in both the ACC/AHA and ESC focused updates include risk stratification, the type and initial timing of P2Y12 inhibitor administration, the duration of DAPT in different patient scenarios, the use of proton pump inhibitors, and the management of antiplatelet therapy in patients on oral anticoagulation.
With respect to specific bleeding risk prediction, the approach of the 2016 ACC/AHA update to risk stratification is essentially qualitative, with a focus on bleeding risk factors rather than an emphasis on predictive models. The ESC guideline on the other hand suggests the use of risk scores designed to evaluate the benefits and risks of different DAPT duration (i.e., PRECISE-DAPT and DAPT scores). Routine platelet function testing to adjust antiplatelet therapy before or after elective stenting is not recommended by the ACC/AHA or ESC due to the neutral results of multiple randomized trials. In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), the recommendation of the 2016 ACC/AHA update for P2Y12 inhibitor therapy, in combination with aspirin (Class of Recommendation [COR] I, Level of Evidence [LOE] B), is “at least 12 months” regardless of the type of stent implanted (COR I, LOE B). Ticagrelor or prasugrel, if no contraindications exist, should be used in preference to clopidogrel for maintenance therapy (COR IIa, LOE B). Similarly, in the 2017 ESC update, the default duration of DAPT for ACS patients undergoing PCI is also 12 months (COR I, LOE A).
The authors concluded that the current ACC/AHA and ESC updates for DAPT are substantially similar with respect to key recommendations on P2Y12 inhibitor selection and DAPT duration.
A careful review by international experts of the current ACC/AHA and ESC updates highlights similarities in key recommendations with some noteworthy differences in approach. While the 2016 ACC/AHA update is centered on DAPT duration, the 2017 ESC document provides broader focus on antiplatelet therapy in general and relative to specific clinical scenarios. An important theme in both updates is the shift from a population-based treatment approach to one that is more individualized, which a step toward an emerging approach for treatment and prevention called “precision medicine.” This approach takes into account individual variability in genes, environment, and lifestyle for each person for prescribing therapies. As our knowledge base improves with ongoing studies, future recommendations will need to be modified to better personalize care for the individual patient.
Keywords: Acute Coronary Syndrome, Adenosine, Aspirin, Blood Platelets, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Platelet Function Tests, Proton Pump Inhibitors, Risk Assessment, Risk Factors, Secondary Prevention, Stents
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