The art of delivering evidence-based dual antiplatelet therapy
This review, which details 2 DAPT risk scoring systems and includes a treatment guide, can help ensure that you deliver the right treatment to the right patients.
PRACTICE RECOMMENDATIONS
› Use a dual antiplatelet therapy (DAPT) risk calculator to encourage patient-centric decisions when presenting information to the health care team and the patient. B
› Consider the potential benefit of a shorter duration of DAPT for patients who 1) have prior bleeding complications or 2) are taking an oral anticoagulant, chronic corticosteroid, or nonsteroidal anti-inflammatory drug. B
› Continue aspirin use upon completion of DAPT or if a P2Y12 inhibitor is being held for surgery. A
› Reduce the risk of recurrent stroke in patients who have had a mild ischemic stroke or transient ischemic attack by providing DAPT for 21 to 28 days, followed by aspirin indefinitely—so long as treatment can begin within 24 hours of the event. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
With a drug-eluting stent, the minimum time for DAPT (using clopidogrel) is 6 months (SOR: A), with a longer duration being reasonable if the patient is not at high risk of bleeding and has had no bleeding complications (SOR: B). For DES patients who have developed a high risk of bleeding, have had significant bleeding, or require a procedure that will place them at high risk of bleeding, DAPT discontinuation can be considered at 3 months (SOR: B).
Updated guidelines allow longer therapy for patients who tolerate DAPT; for them, 12 months of therapy is preferred. In comparing longer and shorter therapy, it has been determined that longer DAPT treatment is superior for reducing the risk of MI and stent thrombosis without increasing the risk of stroke or bleeding complications.20 With increased bleeding, or where there is a need for elective surgery, shortened DAPT is an option.
When treating patients with ACS, including NSTE-ACS or STEMI, DAPT for 1 year is recommended (SOR: A). When medical therapy alone is planned, DAPT is provided with clopidogrel or ticagrelor.
When a patient has been treated with PCI (BMS or DES), DAPT with any of the P2Y12 inhibitors is recommended (SOR: A) unless there is history of stroke or transient ischemic attack (TIA) or the patient is ≥75 years of age, in which case prasugrel is contraindicated (SOR: A: Harm).
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