2017 ESC Focused Update on DAPT in CAD

Valgimigli M, Bueno H, Byrne RA, et al.
2017 ESC Focused Update on Dual Antiplatelet Therapy in Coronary Artery Disease Developed in Collaboration With EACTS: The Task Force for Dual Antiplatelet Therapy in Coronary Artery Disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2017;Aug 26:[Epub ahead of print].

The following are key points to remember about the 2017 European Society of Cardiology (ESC) Focused Update on Dual Antiplatelet Therapy (DAPT) in Coronary Artery Disease (CAD):

  1. Since the benefits of prolonged DAPT beyond 1 year, especially for mortality endpoints, appear highly dependent on prior cardiovascular history (such as prior acute coronary syndrome [ACS]/myocardial infarction vs. stable CAD), and prediction models to estimate on-DAPT bleeding risk have been developed, an individualized approach based on ischemic versus bleeding risk assessment is warranted.
  2. Every effort should be pursued to mitigate the risk of bleeding complications while the patent is on DAPT, including access site selection, modulation of modifiable risk factors for bleeding, low-dose aspirin, low dose of P2Y12 inhibitor as appropriate, and routine use of proton pump inhibitor (PPI).
  3. Clopidogrel is considered the default P2Y12 inhibitor in patients with stable CAD treated with percutaneous coronary intervention (PCI), those with an indication for concomitant oral anticoagulation, as well as in ACS patients in whom ticagrelor or prasugrel are contraindicated. Ticagrelor or prasugrel is recommended in ACS patients unless drug-specific contraindications exist.
  4. For stable CAD patients treated with PCI, irrespective of the type of metallic stent implanted, the duration of DAPT is 1–6 month(s) depending on the bleeding risk. For patients in whom the ischemic risk prevails over the risk of bleeding, a longer DAPT duration may be considered.
  5. Among ACS patients irrespective of the final revascularization strategy (e.g., medical therapy, PCI, or coronary artery bypass grafting), the default DAPT duration in these patients is 12 months. Six-month therapy duration should be considered in high bleeding risk patients, whereas >12-month therapy may be considered in ACS patients who have tolerated DAPT without a bleeding complication.
  6. The need for a short DAPT regimen should no longer justify the use of a bare-metal stent instead of newer-generation drug-eluting stents. DAPT duration in each individual patient should be guided by an individualized approach based on ischemic versus bleeding risk assessment and not by the stent type.
  7. The duration of triple therapy (DAPT + oral anticoagulation) should be limited up to a maximum of 6 months or omitted after hospital discharge, taking into account the ischemic (e.g., complexity of treated CAD, amount of disease left untreated, technical considerations regarding stent implantation techniques, and results) as well as the bleeding risk. The use of ticagrelor or prasugrel in this setting is not recommended.
  8. For patients undergoing elective noncardiac surgery after coronary stent implantation, a multidisciplinary expert team should be considered for preoperative evaluation of patients with an indication for DAPT before elective surgery. Scheduled surgery requiring discontinuation of the P2Y12 inhibitor should be considered after at least 1 month, irrespective of the stent type, if aspirin can be maintained throughout the perioperative period. If both oral antiplatelet agents have to be discontinued perioperatively, a bridging strategy with cangrelor, tirofiban, or eptifibatide may be considered, especially if surgery has to be performed within 1 month after stent implantation.
  9. Similar type and duration of DAPT are recommended in male and female patients, as well as in patients with and without diabetes mellitus.
  10. In patients with active bleeding while on DAPT, the decision to stop both antiplatelet agents, especially if shortly after PCI, should be taken only if the bleeding is life-threatening and the source has not been or cannot be treated. In such a rare case scenario, the patient should be transferred to a primary PCI facility center.

Keywords: Acute Coronary Syndrome, Anticoagulants, Adenosine, Aspirin, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Drug-Eluting Stents, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Proton Pump Inhibitors, Risk Assessment, Risk Factors, Stents, Elective Surgical Procedures, Tyrosine

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