Societies Update Guidelines for Dual Antiplatelet Therapy
Changes update recommendations across six guidelines
WASHINGTON (March 29, 2016) — The American College of Cardiology and the American Heart Association today released updated guidelines for dual antiplatelet therapy in patients with coronary artery disease.
Dual antiplatelet therapy refers to the combination of aspirin with a second aspirin-like but stronger drug referred to as a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor). Dual antiplatelet therapy is used to reduce the risks of future heart attack and coronary stent thrombosis (in which a stent is occluded by a blood clot). These new guideline recommendations are based on the findings of recent studies of the length of time patients with coronary artery disease, specifically those with myocardial infarction (heart attack) and those undergoing coronary stent implantation, should be treated with dual antiplatelet therapy. The new recommendations are also based on current use of coronary stents that have a lower risk of clotting off than some older stents.
The document updates recommendations on duration of dual antiplatelet therapy across six previously published 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.
Studies examining shorter duration (three to six months) of dual antiplatelet therapy compared with a standard 12 months of therapy in select, generally lower-risk patients did not find any increased risk of stent thrombosis and, in some cases, found less bleeding. Other studies of prolonged or extended dual antiplatelet therapy for an additional 18 or 36 months found a decrease in the risk of heart attack and stent thrombosis at the expense of an increase in bleeding risk.
“Treatment with more intensive antiplatelet therapy and treatment for a longer duration of time with antiplatelet medicines in general involves a fundamental tradeoff between a decreased risk of future heart attack and an increased risk of bleeding complications,” said Glenn N. Levine, MD, FAHA, FACC professor of medicine at Baylor College of Medicine and director of the Cardiac Care Unit at the Michael E. DeBakey VA Medical Center in Houston and the chair of the writing committee for the document.
In general, duration of dual antiplatelet therapy recommendations in the document consist of a Class I recommendation of “should be given” for a minimum time period of time (usually six to 12 months), and a Class IIb recommendation of “may be considered” for continuation beyond that time. Shorter duration of dual antiplatelet therapy is recommended for patients at lower ischemic risk with high bleeding risk, whereas longer duration of dual antiplatelet therapy may be reasonable for patients at higher ischemic risk with lower bleeding risk. These recommendations for duration of dual antiplatelet therapy apply to newer-generation stents and, in general, only to those not treated with oral anticoagulant therapy.
A dose of 81 mg daily (range 75-100 mg) is now recommended in patients treated with dual antiplatelet therapy. Regardless of the duration of dual antiplatelet therapy, aspirin therapy is almost always continued indefinitely in patients with coronary artery disease.
The guideline focused update also addresses dual antiplatelet therapy after coronary artery bypass grafting and issues regarding the timing of non-cardiac surgery in patients treated with coronary stent implantation and dual antiplatelet therapy. Decisions about the timing of surgery and whether to discontinue dual antiplatelet therapy after coronary stent implantation involve weighing the particular surgical procedure and the risks of delaying the procedure, the risks of ischemia and stent thrombosis, and the risk and consequences of bleeding, and are thus best individualized.
About the American College of Cardiology
The American College of Cardiology is a 52,000-member medical society that is the professional home for the entire cardiovascular care team. The mission of the College is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more information, visit acc.org.
About the American Heart Association
The American Heart Association is devoted to saving people from heart disease and stroke - America's No. 1 and No. 5 killers. We team with millions of volunteers to fund innovative research, fight for stronger public health policies, and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, call 1-800-AHA-USA1, visit heart.org or call any of our offices around the country. Follow us on Facebook and Twitter.
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