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Acute coronary syndromes, chronic ischaemic heart disease
Optimal duration of dual antiplatelet therapy after acute coronary syndromes and coronary stenting
  1. Alon Eisen,
  2. Deepak L Bhatt
  1. Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Deepak L Bhatt, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; dbhattmd{at}post.harvard.edu

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Learning objectives

  • To provide an overview on the concept of dual antiplatelet therapy (DAPT).

  • To review the evidence regarding shorter and longer DAPT duration.

  • To describe the benefits and risks associated with shorter or longer duration of DAPT in patients with acute coronary syndrome and in patients with stable coronary artery disease after coronary stenting.

  • To suggest an algorithm for optimal duration of DAPT.

Introduction

Dual antiplatelet therapy (DAPT) consisting of aspirin and a P2Y12 receptor antagonist (either a thienopyridine (clopidogrel or prasugrel) or a cyclopentyl-triazolopyrimidine (ticagrelor)) is the cornerstone of antithrombotic treatment after an acute coronary syndrome (ACS) and after coronary stenting. Treatment with DAPT after stent implantation reduces both stent thrombosis (ST) and cardiac ischaemic events that are caused by coronary lesions outside the stented segment, albeit at the cost of an increased risk of bleeding. The optimal duration of DAPT that incorporates this complex interaction between efficacy and safety remains debateable. Although treatment for 12 months with DAPT had been considered a standard of care for years, the plethora of evidence-based data from recent years suggest that shorter or longer durations may yield preferred outcomes in different patient populations.

This article aims to provide readers a thorough and contemporary overview of the evidence, current guidelines’ recommendations and future perspectives on DAPT duration after an ACS and after coronary stenting. In addition, it proposes a simple algorithm of optimal duration of DAPT in these settings.

Background

Dual antiplatelet therapy

Activated platelets play a major role in the pathophysiology of coronary atherothrombosis and thus their inhibition has been the cornerstone of treatment for coronary artery disease (CAD)1 (figure 1). Aspirin, a cyclooxygenase-1 inhibitor, has long been the ‘gold standard’ antiplatelet agent used in the prevention of atherothrombosis, yet despite treatment with aspirin, the risk for recurrent cardiovascular (CV) events remained substantial.2 In the early …

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