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Acute coronary syndromes, chronic ischaemic heart disease
Education in Heart
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

https://doi.org/10.1136/heartjnl-2015-309022

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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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    Footnotes

    • Contributors All authors have participated in the writing of this paper and have reviewed and agree with the content of the article.

    • Competing interests DLB discloses the following relationships—Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today's Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Vice-Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald's Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical; Trustee: American College of Cardiology; Unfunded Research: FlowCo, PLx Pharma, Takeda.

    • Provenance and peer review Commissioned; externally peer reviewed.