This document discusses various topics related to dual antiplatelet therapy (DAPT) including the optimal duration of DAPT after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation. It notes that the appropriate DAPT duration remains controversial and may differ between patients based on their individual risks of ischemia and bleeding. The document also discusses balancing anti-ischemic efficacy against bleeding risk when using antithrombotic therapies and considers strategies like individualizing DAPT duration based on patient characteristics. Triple antithrombotic therapy combining DAPT and oral anticoagulants for patients with atrial fibrillation is also reviewed.

1. 2015 Great Debate

2. ? Single-antiplatelet therapy (SAPT) versus
Dual-antiplatelet therapy (DAPT)
? Longer – versus shorter – duration DAPT
Answers to difficult questions in DAPT

5. Antiplatelet Agents—Oral P2Y12 Inhibitors
++++++Bleeding Risk

6. Spectrum of Coronary Artery Disease
Acute
Coronary
Syndromes
Stable
Coronary
Artery
Disease

11. Moderate to high-risk NSTEACS as defined in PLATO: ≥2 of: (1) ischemic ST changes on ECG; (2) positive biomarkers;and
(3) 1 of the following: 60 years of age or greater, previous MI or CABG, CAD > 50% stenosis in 2 vessels, previous ischemic
stroke, diabetes,peripheral arterial disease, or chronic renal dysfunction.
Canadian Journal of Cardiology 29 (2013) 1334-1345

12. Canadian Journal of Cardiology 29 (2013) 1334-1345
Prasugrel should be avoided in patients with previous TIA or stroke.
In patients aged 75 years and older, or body weight <60 kg, prasugrel should be used with caution and
a 5-mg dose considered

13. Canadian Journal of Cardiology 29 (2013) 1334-1345
Prasugrel should be avoided in patients with previous TIA or stroke.
In patients aged 75 years and older, or body weight <60 kg, prasugrel should be used with caution and a 5-
mg dose considered

14. Canadian Journal of Cardiology 29 (2013) 1334-1345
Antiplatelet Therapy Post-CABG

15. ? Single-antiplatelet therapy (SAPT)
? Dual-antiplatelet therapy (DAPT)

16. Management of SCAD patients
Angina relief Event prevention
• β-blockers and/or CCB
 Ivabradine
 Long-acting nitrates
 Nicorandil
 Ranolazine
 Trimetazidine
• Lifestyle management
• Control of risk factors
Consider coronary angio → PCI or CABG
Short-acting nitrates, plus
1st line
2nd line
2013 ESC guidelines on the management of stable coronary artery disease.

17. SCAD
Medical Elective PCIElective CABG
Single-antiplatelet therapy (SAPT) Dual-antiplatelet therapy (DAPT)
Aspirin (Indefinite Therapy)
If aspirin intolerant :
Clopidogrel (Indefinite Therapy)
Aspirin plus Clopidogrel
 BMS : 1 month
 DES : 6-12 months

18. The Balance between Anti-ischemic Efficacy and
Bleeding Risk of Antithrombotic Therapy in PC I

19. Thus, the thousand dollar question is : Where is the sweet spot
between ischaemia and bleeding?

20. What is the optimal duration of
DAPT after PCI?
Where is the sweet spot between
ischaemia and bleeding?

22. Randomized controlled trials investigating less than 12 months of DAPT
did not show significant differences in their composite endpoints
compared with 12 months or prolonged DAPT.
European Heart Journal
(2015) 36, 1207–1211

23. Rates of bleeding are consistently higher for prolonged
DAPT, reaching statistical significance in some studiesEuropean Heart Journal (2015) 36, 1207–1211

24. The appropriate duration of DAPT for patients following
placement of a DES remains controversial.

25. The “Will this trial change my practice?” sessions at
PCR 2015
Will this trial change my practice?
The Dual Antiplatelet Therapy (DAPT) study – 12 or 30 months of dual
antiplatelet therapy after drug-eluting stents
Should the DAPT study shift the standard of care from 12
months to 30 months in patients who receive a DES?
 Does the increased risk of bleeding essentially offset the
benefits?
 To whom would you recommend continued DAPT?
 In whom would you avoid it?

26. A call for individualised medicine
(precision medicine or personalized medicine)
How long should DAPT be continued ?
3, 6, 12, 24, 30 months
The therapeutic sweet spot between reduced ischaemia and
increased bleeding markedly differs between patients.
The currently available evidence
speaks for individualising
the duration of DAPT, taking the
patient’s risk for ischaemic and
haemorrhagic events into
account

28. Pharmacogenomics : Determining the right
drug in the right dosage at the right time for
each and every patient

29. Thromb Haemost 2015; 113: 37–52
Pharmacogenomics

30. Ischemic RiskBleeding Risk
Balanced Benefit/Risk Ratio
Tailoring antiplatelet therapy :
a step toward individualized therapy to improve clinical outcome?

31. Proposed duration of dual antiplatelet therapy after DES
(based on individual risk)
European Heart Journal (2015) 36, 1207–1211

32. Long-term risk factors for stent thrombosis after PCI
Pharmacological
factors
Patient
characteristics
Procedural
factors
-Premature
discontinuation
of DAPT
-Slow metabolizers of
the antiplatelet
pro-drug
-Diabetes
-ACS
-LV dysfunction
-Malignancy
-Stent type
-Stent undersizing
-Incomplete stent expansion
-Incomplete apposition
-Greater stent length
-Side branch stenting
-Overlapping stents
-Small vessel calibre
European Heart Journal (2015) 36, 1207–1211

33. Pharmacological
factors
Patient
characteristics
Procedural
factors
-Prolonged DAPT
-Concomitant use
of OAC
-Age
-History of bleeding
-Low body weight
-ACS
-Thrombocytopenia
-GI disease
-Impaired kidney function
-Liver disease
-Cerebrovascular accident
-Malignancy
Short-term risk
factors:
-Femoral access,
-Large sheath size
-No vascular
closure device
Long-term risk
factors:
-Unknown
Long-term risk factors for bleeding after PCI
European Heart Journal (2015) 36, 1207–1211

34. Factors for physicians to consider in determining the optimal
duration of DAPT after DES implantation for individual patients
Eisen, A. & Bhatt, D. L. (2015) Defining the optimal duration of DAPT
after PCI with DES Nat. Rev. Cardiol. doi:10.1038/nrcardio.2015.87

35. Triple Antithrombotic Therapy
Dual-antiplatelet therapy (DAPT) + Oral AntiCoagulant (OAC )
Oral AntiCoagulants
(OACs)
Vitamin K Antagonist
(VKA) Warfarin
Factor IIa
Dabigatran
Factor Xa
Rivaroxaban
Apixaban
Non-VKA oral anticoagulants (NOACs),
previously referred to as new or novel OACs

37. Triple Antithrombotic Therapy
Risky but sometimes necessary
Dual-antiplatelet therapy (DAPT):
Oral AntiCoagulant (OAC):

40. Continuing
DAPT + OAC
Bleeding
risk
Discontinuing
OAC
Stroke risk
Discontinuing
DAPT
Stent
thrombosis
risk
Triple Antithrombotic Therapy
in AF patients with ACS/PCI
Issues for Mr. X

41. Joint consensus document :European Heart Journal (2014)

42. Clinical setting
Elective PCI in stable CAD
ACS (either STEMI or NSTEMI )
Stroke risk
CHA2DS2-VASc score
Bleeding risk
HAS-BLED score
Antithrombotic therapy
Triple(OAC+DAPT) , dual(OAC+SAPT) , mono(OAC)
Antithrombotic management in NVAF patients with ACS/PCI

43. Non-valvular AF : Stroke risk

45. Elective PCI in SCAD
High
(CHA2DS2-VASC
≥2)
Moderate
(CHA2DS2-VASC =1 in
males ,=2 in women)
Low or moderate (HAS-BLED 0–2)
At least 4 weeks (no longer than 6
months): triple therapy of OAC +
aspirin + clopidogrel
Up to 12th month: OAC and clopidogrel
(or alternatively,aspirin)
Lifelong : OAC
ACS
High
(CHA2DS2-VASC
≥2)
Moderate
(CHA2DS2-VASC =1 in
males,=2 in women)
Low or moderate (HAS-BLED 0–2)
6 months: triple therapy of OAC +
aspirin + clopidogrel
Up to 12th month: OAC and clopidogrel
(or alternatively,aspirin)
Lifelong: OAC
OAC and clopidogrel

46. Elective PCI in SCAD
Moderate
(CHA2DS2-VASC =1 in
males,=2 in women)
High (HAS-BLED ≥3)
12 months: OAC and
clopidogrel
Lifelong: OAC
ACSElective PCI in
SCAD
High
(CHA2DS2-VASC
≥2)
Moderate
(CHA2DS2-VASC
=1 in males,=in
women)
High
(CHA2DS2-VASC
≥2)
High (HAS-BLED ≥3)
4 weeks: triple therapy of OAC + aspirin + clopidogrel
Up to 12th month: OAC and clopidogrel (or
alternatively,aspirin)
Lifelong: OAC
OAC and clopidogrel

47. For PCI, BMS may be considered to minimize
duration of DAPT Class IIb C
After coronary revascularization in patients with
CHA2DS2-VASc score ≥2, it may be reasonable to use
clopidogrel concurrently with oral anticoagulants but
without aspirin Class IIb B

48. The balance of bleeding and ischaemic
events in surgical patients after
stenting.
Continuing DAPT
Bleeding risk
Discontinuing DAPT
Stent thrombosis
risk
Issues for Mr. X

49. Surgery in patients on dual antiplatelet therapy

50. Proposedbridging protocols for patients on dual-antiplatelettherapy withaspirinplus a P2Y12
receptor inhibitor referred to cardiac or noncardiac surgery.
Davide Capodanno, and Dominick J. Angiolillo Circulation.
2013;128:2785-2798
Copyright © American Heart Association, Inc. All rights reserved.

51. Rabeprazole------------- PARIET
Pantoprazole -----------CONTROLOC
Omeprazole--------------LOSEC
Lansoprazole -----------LANZOR
Esomeprazole ---------NEXIUM

52. (Circ Cardiovasc Qual Outcomes. 2015)

54. Light transmission
aggregometry (LTA)

55. Factors linked to clopidogrel response
variability. Thromb Haemost 2015; 113: 37–52

56. A proposed algorithm for personalised
antiplatelet treatment with P2Y12
receptor blockers

57. *The PREDICT
score might be
used when
ticagrelor or
prasugrel are not
available or
contraindicated.