What is the role of antiplatelet therapy in the treatment of coronary artery atherosclerosis prevented?

Updated: Apr 09, 2021
  • Author: Sandy N Shah, DO, MBA, FACC, FACP, FACOI; Chief Editor: Yasmine S Ali, MD, MSCI, FACC, FACP  more...
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Answer

Guidelines

The 2007 ACC/AHA guidelines recommend that after an ACS, all patients should receive dual antiplatelet therapy, ideally for 12 months, followed by lifelong aspirin therapy. [1] The ACCF/ACG/AHA 2010 expert consensus provides a detailed report on reducing the gastrointestinal risks of antiplatelet therapy and nonsteroidal anti-inflammatory drug (NSAID) use. [66]

The European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) released their focused update on dual antiplatelet therapy (DAPT) in CAD in 2017. [67, 68] Some of their important recommendations are summarized below.

The latest advice in this controversial area advocates a personalized-medicine approach based on ischemic versus bleeding risks, where each treatment and its duration is individualized as much as possible.

DAPT (aspirin plus a P2Y12 inhibitor) reduces the risk of stent thrombosis and/or spontaneous myocardial infarction (MI) in patients following percutaneous coronary intervention (PCI) or an acute coronary syndrome (ACS). 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 previous cardiovascular history (such as prior ACS/MI vs stable CAD).

For ACS patients, the default DAPT duration should be 12 months, irrespective of the revascularization strategy (medical therapy, PCI, or coronary artery bypass graft [CABG] surgery). Six months of DAPT should be considered in patients at high bleeding risk (PRECISE-DAPT score ≥25). Therapy longer than 12 months may be considered in ACS patients who have tolerated DAPT without a bleeding complication.

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 addition of DAPT to oral anticoagulation therapy increases the risk of bleeding complications by twofold 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 CAD vs ACS).


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