Dual antiplatelet therapy after coronary stenting

ABSTRACT

Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ receptor inhibitor represents the mainstay of pharmacotherapy in patients undergoing coronary stenting. Currently, three P2Y₁₂ receptor inhibitors are approved for clinical use, including clopidogrel, prasugrel, and ticagrelor, with the latter two being preferred in patients presenting with an acute coronary syndrome. The introduction into clinical practice of newer-generation drug-eluting stent (DES) with safer profiles (i.e. less stent thrombosis) compared with earlier platforms have led recent guideline updates to re-evaluate the optimal duration of DAPT therapy, which are now based on evidence of a multitude of randomized clinical trials, registries, and meta-analysis and take into consideration the ischemic and bleeding risk profile of the patients.

Areas covered: Most recent updates on DAPT duration from professional societies in the United States and Europe are discussed. Moreover, an assessment of clinical trials, registries, and meta-analysis leading to changes on practice guidelines analyzed.

Expert opinion: The widespread introduction into clinical practice of newer-generation DES allows for shortening DAPT duration as also endorsed by practice guidelines. However, the optimal duration of DAPT therapy varies according to the individuals’ risk of ischemic and bleeding complications, with longer or shorter durations of treatment, respectively, that may be considered.

KEYWORDS:

• Antiplatelet therapy
• duration of antiplatelet therapy
• coronary artery disease
• coronary stent

Article highlights

• The recent advances of stent technologies demonstrating a better safety (i.e. less stent thrombosis) support a shorter period of DAPT coverage after coronary stenting.

• DAPT duration varies according to clinical presentations and the type of stent implanted. At least 12-month DAPT for ACS patients is recommended irrespective of stent type (DES or BMS), whereas 1-month DAPT after BMS implantation and 6-month DAPT after newer-generation DES coronary stent implantation is recommended for SIHD patients.

• Shorter DAPT after DES implantation can be considered in patients at high risk of bleeding or develop significant bleeding.

• Prolonged DAPT reduces the risk of ischemic events after coronary stenting, at the expense of increased bleeding risks. Further continuation of DAPT is reasonable only for patients at high ischemic and at low bleeding risk without a prior bleeding event.

• Guidelines recommend continuation of DAPT >12 months after MI only in patients at low bleeding risk who have well tolerated DAPT.

Decisions about further continuation of DAPT should depend on the balance between ischemic and bleeding risks. New scoring systems may help clinicians to identify individual benefit/risk ratio from prolonged DAPT.

This box summarizes key points contained in the article.

Declaration of interest

D.J. Angiolillo has received payment as an individual for: a) Consulting fee or honorarium from Sanofi, Eli Lilly, Daiichi-Sankyo, The Medicines Company, AstraZeneca, Merck, Abbott Vascular and PLx Pharma; b) Participation in review activities from CeloNova, Johnson & Johnson, and St. Jude Medical. Institutional payments for grants from Glaxo-Smith-Kline, Eli Lilly, Daiichi-Sankyo, The Medicines Company, AstraZeneca, Janssen Pharmaceuticals, Inc., Osprey Medical, Inc., Novartis, CSL Behring, and Gilead. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.