ESC Guideline Update on Dual Antiplatelet Therapy in CAD

September 14, 2017

BARCELONA, SPAIN — The European Society of Cardiology has issued a new "focused update" on its guidelines on dual antiplatelet therapy (DAPT)—aspirin plus a P2Y12 inhibitor—in coronary artery disease (CAD).

The update, announced at the European Society of Cardiology (ESC) 2017 Congress and published online in the European Heart Journal on August 26, 2017, was developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).

"This update includes a major concept change from previous recommendations in that it focuses much more on personalized medicine, and each patient's individual bleeding risk is now more central to decision-making about the type and duration of DAPT," chair of the update task force, Dr Marco Valgimigli (Inselspital Universitätsspital Bern, Switzerland), told | Medscape Cardiology.

"Previously we haven't had the tools to scientifically assess bleeding risk, but now we have a new score—the PRECISE DAPT score—which takes into account patient characteristics such as age, renal function, history of bleeding, etc, to help us quantify bleeding risk more accurately. This is allowing more individual decisions to be made," he explained.

They are now advocating 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 outlining how to maximize the expected benefits over the risks," Valgimigli said.

"For example, in patients with a bleeding risk higher than average, we are now recommending shorter duration of DAPT, as there is good evidence that the bleeding risks of longer therapy outweigh the benefits. And conversely, in patients with lower-than-average bleeding risk, the benefits of longer DAPT generally outweigh the bleeding risk."

Valgimigli noted that dual antiplatelet therapy 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."

The update explains that DAPT reduces the risk of stent thrombosis and/or spontaneous MI in patients following PCI or an 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 prior cardiovascular history (such as prior ACS/MI vs stable CAD).

Valgimigli pointed out that the most contentious issue is the need for a prolonged DAPT regimen (beyond 12 months) in ACS patients treated with PCI. "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," he stated.

Key messages in the update include the following:

  • For ACS patients, the default DAPT duration should be 12 months, irrespective of the revascularization strategy (medical therapy, PCI, or 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 vs 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 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 (Brilinta/Brilique, AstraZeneca) or prasugrel (Effient/Efient, Eli Lilly/Daiichi Sankyo) 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).

Valgimigli reports speaker fees or honoraria from and consulting, advisory board membership, being an investigator, or committee member for AstraZeneca, Terumo, Abbott Vascular, Sinomed, Bayer, and Correvio; and research funding to his department or institution from AstraZeneca, Medicure, Terumo, and the Medicines Company. Disclosures for the coauthors are listed here.

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