Long-term antiplatelet therapy after coronary artery stenting in stable patients

1. Long-term antiplatelet therapy after
coronary artery stenting in stable
patients
Donald Cutlip, MD
Jose C Nicolau, MD, PhD, FACC
Uptodate
Last updated: Feb 25, 2016.
Juan J. Araya C.
Interno Medicina Interna – Universidad de Antofagasta
Módulo Cardiología

2. Duration
 Patients with stable coronary artery disease who have undergone
percutaneous coronary intervention (PCI) with stenting (either bare metal
stent [BMS] or drug-eluting stent [DES]), we recommend aspirin 75
to 100 mg daily plus clopidogrel 75 mg daily for at least 12 months.
 who have tolerated this therapy,  additional 18 months.
 With high bleeding risk  less than 1 year of DAPT
– a history of ischemic attack or stroke
– age ≥75 years, propensity to bleed (eg, recent trauma or surgery, recent or
recurrent gastrointestinal bleeding, active peptic ulcer disease, severe hepatic
impairment),
– body weight <60 kg,
– oral anticoagulants or nonsteroidal antiinflammatory drugs [NSAIDs]

3.  Occasionally, patients may unexpectedly need to
stop DAPT prior to 12 months.
– the “minimum” duration of uninterrupted
terapy is 30 days.
 If a bleeding event occurs or the bleeding risk
is high, we consider limiting therapy to as short
as 1 month in some cases. (the risk of stent thrombosis
with BMS is greatest in the first 14 to 30 days)
Duration

4.  For patients who have successfully completed
1 year of DAPT,  discuss with them benefits
and risks of continuing therapy
 DAPT SCORE:
– score of <2  stop at 12 months.
– Score >= 2 continue therapy for an additional 18 months
To be used in conjunction with clinical judgement.
Duration

5. Mauri et al., NEJM 2014.

6.  A 2015 meta-analysis (nine trials including 29,531
patients), which is representative, found the following
comparing longer- with shorter-duration DAPT :
– A lower risk for MI (risk ratio [RR] 0.73, 95% CI 0.58-
0.92). This represents 8 fewer MIs per 1000 treated
patients per year.
– A higher risk for major bleeding (RR 1.63, 95% CI 1.34-
1.99). This represents 6 more major bleeds per 1000
patients treated per year.
Duration

7.  Bare metal stents:
– For patients who have received BMS, our
recommendations are the same as for DES.
– The DAPT trial provided evidence to suggest that the benefit
for prolonged DAPT is largely independent of
stent type.
 ACS treated medically (no PCI):
– DAPT, compared with aspirin alone, reduces the rate of MI
Duration

8. SUMMARY AND
RECOMMENDATIONS
 The risk of coronary artery stent thrombosis and its consequences of
myocardial infarction (MI) or death are diminished by the use of dual
antiplatelet therapy (DAPT) with aspirin and a platelet
P2Y12 receptor blocker compared with the use of aspirin
monotherapy.
 Stable patients with (DES/BMS)  not at high
bleeding risk and who do not have planned
noncardiac surgery within one year,  least 12
months (1B).

9.  1 year of successful DAPT therapy,  discuss benefits
and risks of continuing DAPT.
–  use the DAPT score to aid in decision-making.
 If during the first 12 months not had a significant
complication  additional 18 months (Grade 2B).
 It is reasonable for patients to decide to stop DAPT after 12 months if they
are particularly concerned about the increased risk of death or bleeding or
due to a hardship associated with continuing DAPT.
SUMMARY AND
RECOMMENDATIONS (2)

10.  BMS patients at high bleeding risk or who have
planned noncardiac surgery within one year, 
minimum of 1 month of uninterrupted DAPT (Grade
1B).
 DES patients uninterrupted DAPT for a minimum of
6 months (Grade 1B).
 We recommend continuing aspirin indefinitely in all
stented patients (Grade 1A).
SUMMARY AND
RECOMMENDATIONS (3)

11. ACC/AHA
2014

12. UA / NSTEMI
No stent ASA 162–325 mg promptly after
presentation then a maintenance dose of
ASA 81–162 mg daily continued indefinitely,
PLUS a P2Y12 inhibitor for up to 12
months; one of:
• Clopidogrel 300 or 600 mg loading dose
then 75 mg daily • Ticagrelor 180 mg
loading dose then 90 mg twice daily
Bare-metal stent ASA 162–325 mg promptly after
presentation then a maintenance dose of
81–325 mg daily continued indefinitely,
PLUS a P2Y12 inhibitor for at least 12
months or beyond; one of:
• Clopidogrel 300 or 600 mg loading dose
then 75 mg
daily
• Prasugrel 60 mg loading dose then 10 mg
daily
• Ticagrelor 180 mg loading dose then 90
mg twice daily
Drug-eluting stent As for bare-metal stent

13. STEMI
No stent For patients who underwent fibrinolysis:
ASA 162–325 mg loading dose then
maintenance dose of 81–325 mg daily
continued indefinitely, PLUS clopidogrel
loading dose of 300 mgh then 75 mg daily
for at least 14 days and up to 12 months
For patients who underwent PCI without
stent placement – recommendations as for
those listed for Bare-metal stent
Bare-metal stent ASA 162–325 mg promptly after
presentation then a maintenance dose of
81–325 mg daily continued indefinitely,
PLUS a P2Y12 inhibitor for at least 12
months or beyond; one of:
• Clopidogrel 300 or 600 mg loading dose
then 75 mg daily
• Prasugrel 60 mg loading dose then 10 mg
daily
• Ticagrelor 180 mg loading dose then 90
mg twice daily
Drug-eluting stent As for bare-metal stent