March 30, 2016
In updated guidelines, the American College of Cardiology (ACC) and the American Heart Association (AHA) recommended that the duration of dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor in patients with coronary artery disease (CAD) be determined on an individualized basis, taking into account a patient’s ischemic and bleeding risks.
DAPT is an effective means of decreasing the risk of ischemia in patients with CAD, but it is also associated with an increased risk of bleeding. Therefore, these two risks must be weighed for each patient when determining the appropriate duration of DAPT.
The updated review considered the results of 11 studies of patients treated with coronary stent implantation assessing shorter-duration or longer-duration DAPT. An additional, large, randomized controlled study assessing DAPT compared with aspirin monotherapy in patients 1 to 3 years after myocardial infarction was also reviewed. All studies took place after prior DAPT guidelines had been released.
In light of the updated evidence, the guidelines recommend that, in most clinical settings, 6 to 12 months of DAPT should be considered (Class I recommendation), and use beyond this initial period may be considered (Class IIb recommendation). Shorter-duration (3 to 6 months) DAPT can be considered for patients with lower ischemic risk but with high bleeding risk, whereas longer-duration (18 to 48 months) DAPT may be reasonable for patients at higher ischemic risk with low bleeding risk. Clinical judgment, assessment of individual risks and benefits, and patient preferences should also be considered when determining duration of DAPT for an individual patient.
These recommendations only apply to the therapy with P2Y12 inhibitors plus aspirin in patients with CAD. Aspirin use should be continued in these patients at a recommended daily dose of 81 mg (range, 75 mg to 100 mg). Patients on oral anticoagulation were not included in most of the studies analyzed; therefore, the recommendations do not apply to these patients.
The new recommendations provide an update to six previously released guidelines: the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (PCI), the 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, the 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, the 2014 ACC/AHA Guideline for Non-ST-Elevation Acute Coronary Syndromes, and the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.
Reference: Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease [published online March 2016]. J Am Coll Cardiol. doi: 10.1016/j.jacc.2016.03.513.