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
For emergent surgery, when severe bleeding is not seen or expected, interruption of DAPT can be minimized. After cessation of DAPT components, normal platelet function will return in12:
- 7 to 10 days for ASA,
- 5 to 7 days for prasugrel,
- 5 days for clopidogrel, and
- 3 to 5 days for ticagrelor.
If significant bleeding occurs perioperatively, or is expected, platelet transfusion can be helpful, and might need to be repeated because each P2Y12inhibitor has a half-life of between 8 and 12 hours.
For urgent or time-sensitive surgery, discontinuing a P2Y12inhibitor can be considered—while continuing ASA, if possible. DAPT should be restarted as soon as safely possible. If enteral administration is not feasible, ASA can be administered rectally. In this setting, cardiology consultation is strongly encouraged.
Last, elective surgery should be delayed until DAPT is completed, but without discontinuing ASA, if feasible. Spinal, intracranial, prostate, middle-ear, and ophthalmologic surgery while taking ASA can lead to catastrophic complications; consider discontinuing ASA. Cardiology consultation can provide an estimate of thrombosis risk to guide clinical decision-making.30
Can DAPT prevent secondary stroke?
DAPT has brought improvements in the treatment of patients with cardiovascular disease; it has been hypothesized that similar benefits can be seen in patients with ischemic stroke. Knowing the cause of stroke is key to developing a secondary prevention plan; patients with stroke secondary to atherosclerotic disease are most likely to benefit from DAPT.31 Conversely, secondary prevention in patients with small-vessel disease and in studies of unselected stroke type has been shown to be harmful.32,33
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