ESC Focused Update on DAPT in Coronary Artery Disease Published
September 5, 2017—The European Society of Cardiology (ESC) announced that the first ESC focused update on dual antiplatelet therapy (DAPT) in coronary artery disease was published online in European Heart Journal and on the ESC website. The document was developed in collaboration with the European Association for Cardio-Thoracic Surgery.
Task Force Chairperson Marco Valgimigli, MD, commented in the ESC announcement, “DAPT is a controversial topic on which a lot of conflicting evidence has been generated. This has led to a great deal of uncertainty in the medical community, particularly regarding the optimal duration of DAPT after coronary stenting.”
As summarized by ESC, chapters in this focused update include DAPT and percutaneous coronary intervention (PCI); DAPT and cardiac surgery; DAPT for patients with medically managed acute coronary syndrome (ACS); DAPT for patients with an indication for oral anticoagulation; elective noncardiac 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 reduces the rate of spontaneous myocardial infarction (MI)after MI or PCI. The risk of bleeding in patients on DAPT is proportionally related to its duration. The benefits of prolonged DAPT, especially on mortality, depend on the patient's cardiovascular history (e.g., previous ACS/MI vs stable coronary artery disease).
According to ESC, the document recommends the use of prediction models to estimate on-DAPT bleeding risk and advocates an individualized approach based on ischemic versus bleeding risks.
The ESC noted that the most contentious issue was the need for a prolonged DAPT regimen (beyond 12 months) in ACS patients treated with PCI. Dr. Valgimigli stated, "This is a setting in which one needs to think twice about how to maximize the benefits over the risks. 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.”
As summarized by ESC, the Task Force recommends that the default DAPT duration for ACS patients should be 12 months, irrespective of the revascularization strategy (medical therapy, PCI, or coronary artery bypass graft surgery [CABG]). For patients at high bleeding risk, 6 months of DAPT should be considered. Therapy longer than 12 months may be considered in ACS patients who have tolerated DAPT without a bleeding complication.
The document emphasizes 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. DAPT duration should be guided by an assessment of the individual patient’s ischemic 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 1 to 6 months, depending on the bleeding risk. A longer DAPT duration may be considered in patients whose ischemic risk is greater than the risk of bleeding.There are insufficient data to recommend DAPT in stable CAD patients treated with CABG.
The guidelines note that the addition of DAPT to oral anticoagulation therapy increases the risk of bleeding complications by two- to threefold. 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 6 months or omitted after hospital discharge depending on the ischemic and bleeding risks.
Clopidogrel is recommended as the default P2Y12 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 P2Y12 inhibitor depends on both the specific drug and the specific disease (stable coronary artery disease vs 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 commented, “The Task Force advocates a personalized medicine approach where each treatment and its duration is individualized as much as possible. The document highlights who should, and should not, receive long-term treatment, while at the same time outlining how to maximize the expected benefits over the risks.”
This focused update is accompanied by a 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, stated ESC.