Dr Akash Gangane explains Antiplatelets in IHD, Dose Duration, DAPT vs SAPT

1. Antiplatelets In IHD

2. Points to be covered
• Current antiplatelet drugs
• DAPT
• Antiplatelets in
1. stable angina with no intervention.
2. stable angina with intervention.
3. unstable angina.
4. ACS Treated With Medical Therapy Alone.
5. ST-elevation (STE)-ACS and receiving fibrinolytic therapy.
6. ACS and Primary PCI
7. CABG

3. Current oral antiplatelets used in IHD

4. DAPT
Aspirin (low dose) + P2Y12 inhibitor
• PLATO Trial - A significant reduction in mortality occurred with ticagrelor
compared to clopidogrel.
• TRITON study - Demonstrated no net benefit of prasugrel compared with
clopidogrel for patients with low body weight (<60 kg) or those ≥75 years of age .
Found net harm with prasugrel for patients with previous transient ischemic attack
or cerebrovascular accident.
• POPular AGE study - In patients aged 70 years or older presenting with NSTE-
ACS, clopidogrel is a favourable alternative to ticagrelor, because fewer bleeding
events were found without an increase in the combined endpoint of all-cause
death, myocardial infarction, stroke, and bleeding.

5. 1) Stable Angina no intervention
• In patients with stable angina low-dose aspirin is recommended to
reduce atherosclerotic events.
• Dose - 81 mg (75-100 mg)
• Routine combination of aspirin and a P2Y12 inhibitor is not
recommended due to an excessive risk of bleeding.
• European Society of Cardiology recommend daily use of low-dose
aspirin, and if allergic to aspirin then Clopidogrel can be used.

6. Aspirin monotherapy or Clopidogrel monotherapy?
• In Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events
(CAPRIE) trial interpreted that there was a relative increase (3.7%) in
risk of Myocardial infarction with clopidogrel only group.
• Clopidogrel reduced the rate of ischemic rehospitalizations compared
with aspirin when all 3 risk factors were taken into account -
Ischaemic stroke, myocardial infarction, or vascular death

8. 2) Stable Angina with intervention
In patients with SIHD revascularized with
BMS - DAPT given for minimum of 1 month
DES - DAPT should be given for at least 6 month.
(DAPT – low dose aspirin (75-100) and P2Y12
Inhibitor

10. Unstable Angina
• Aspirin (ASA) is the first choice and is administered as soon as
possible after presentation and continued indefinitely.
• clopidogrel should be administered to patients who are unable to take
ASA because of hypersensitivity or major gastrointestinal intolerance.
• A loading dose of non–enteric-coated aspirin 162 mg to 325 mg is the
initial antiplatelet therapy.
• Maintenance dose is 75 mg per day to 150 mg per day , lifelong.

11. CURE trial.
• Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events
(CURE) trial.
• Among 12562 patients, the combination of clopidogrel and aspirin
lowered the composite of death, MI, or stroke by 21% at 30 days
compared with aspirin alone.

12. CURE Trial

13. In patients with ST-elevation (STE)-ACS and
receiving fibrinolytic therapy
• With an initial non-invasive strategy, add a loading dose followed by
daily maintenance dose of clopidogrel or ticagrelor to aspirin (DAPT)
and anticoagulation as soon as possible after admission and up to 12
month
• Ticagrelor has rapid onset of action compared with clopidogrel, while
also allowing a higher level of platelet inhibition and more rapid
reversal compared with clopidogrel. (PLATO STUDY)

15. Duration of DAPT in Patients With ACS Treated With
Medical Therapy Alone
• NO revascularization or fibrinolytic therapy – DAPT [Low dose
aspirin and P2Y12 inhibitor therapy (clopidogrel or ticagrelor)]
should be continued for at least 12 months(COR-1).
• In patients with NSTE–ACS who are managed with medical
therapy alone and treated with DAPT, it is reasonable to use
ticagrelor in preference to clopidogrel for maintenance P2Y12
inhibitor therapy.(COR-2A)

16. Duration of DAPT in Patients With STEMI Treated With Fibrinolytic Therapy
• In patients with STEMI treated with fibrinolytic therapy, DAPT
therapy should be continued for a minimum of 14 days and ideally
at least 12 months.(COR-1)
• And if they tolerate DAPT without bleeding complication and who
are not at high bleeding risk (e.g., prior bleeding on DAPT,
coagulopathy, oral anticoagulant use), continuation of DAPT for
longer than 12 months may be reasonable.(COR- 2B)

18. In Patients with ACS and Primary PCI
• 2021 , Class I and IIa American College of Cardiology/American Heart
Association Guideline Recommendations for Antiplatelet Therapy in
Patients Receiving Primary PCI-
• Aspirin 162 to 325 mg load before procedure f/b 75-100mg daily
maintenance dose.
• Clopidogrel load: 600 mg as early as possible or at time of PCI. f/b 75mg
daily for 1 year.
• Prasugrel load: 60 mg as early as possible or at time of PCI f/b 10mg daily
for 1 year.
• Ticagrelor load: 180 mg as early as possible or at time of PCI f/b 90mg teice
a day for 1 year.

19. COR Recommendations
I
In patients withACS (NSTE-ACS or STEMI) treated with
DAPT after BMS or DES implantation, P2Y12 inhibitor therapy
(clopidogrel, prasugrel, or ticagrelor) should be
given for at least 12 months.
I
In patients treated with DAPT, a daily aspirin dose of 81 mg
(range, 75 mg to 100 mg) is recommended.
IIa
In patients withACS (NSTE-ACS or STEMI) treated with
DAPT after coronary stent implantation, it is reasonable to
use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor
therapy.
IIa
In patients withACS (NSTE-ACS or STEMI) treated with
DAPT after coronary stent implantation who are not at high risk for bleeding
complications and who do not have a history of stroke or TIA, it is reasonable
to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy.
Duration of DAPT in Patients With ACS Treated With PCI

20. Duration of DAPT in Patients With ACS Treated With PCI
COR Recommendations
IIb
In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent
implantation who have tolerated DAPT without a bleeding complication and who
are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral
anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for
longer than 12 months may be reasonable .
IIb
In patients with ACS treated with DAPT after DES implantation who develop a high
risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high risk of
severe bleeding
complication (e.g., major intracranial surgery), or develop significant overt
bleeding, discontinuation of P2Y12 inhibitor therapy after 6 months may be
reasonable.
III:
Harm
Prasugrel should not be administered to patients with a prior history of stroke or
TIA.

22. Recommendations for Duration of DAPT in
Patients Undergoing CABG
COR Recommendations
I
In patients treated with DAPT after coronary stent implantation who subsequently
undergo CABG, P2Y12 inhibitor therapy should be resumed postoperatively so that
DAPT continues until the recommended duration of therapy is completed.
I
In patients withACS (NSTE-ACS or STEMI) being treated with DAPT who
undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to
complete 12 months of DAPT therapy afterACS.
I
In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100
mg) is recommended.
IIb
In patients with SIHD, DAPT (with clopidogrel initiated early postoperatively) for
12 months after CABG may be reasonable to improve vein graft patency.

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