Should you switch the DAPT agent one month after ACS?
A randomized controlled trial says “Yes,” but current guidelines say “No.”
PRACTICE CHANGER
Switch to clopidogrel from one of the newer P2Y12 blockers 1 month after an acute coronary event, while continuing aspirin, to decrease bleeding events without increasing the risk of ischemic events.1
STRENGTH OF RECOMMENDATION
B: Based on a single randomized controlled trial (RCT).
Cuisset T, Deharo P, Quilici J, et al. Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. Eur Heart J. 2017;38:3070-3078.
CAVEATS
Less-than-ideal study methods
This trial was an open-label, unblinded study. The investigators who adjudicated critical events were blinded to the treatment allocation, but some events, such as minor bleeding and medication discontinuation, could be self-reported by patients. In addition, the investigators used a less-than-ideal method (opaque envelopes) to conceal allocation at enrollment.
CHALLENGES TO IMPLEMENTATION
Implementation may require changing a cardiologist’s prescription
Implementing this practice change is facilitated by the fact that clopidogrel is currently less expensive than the newer P2Y12 blockers. However, after ACS and PCI treatment, cardiologists usually initiate antiplatelet therapy and may continue to manage patients after discharge. So the family physician (FP) may not be responsible for the DAPT switch initially. Further, switching may necessitate coordination with the cardiologist, as FPs may be hesitant to change cardiologists’ prescriptions. Lastly, guidelines currently recommend using the newer P2Y12 blockers for 12 months.2
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
