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
Summing up: Key guidance
DAPT has benefits for patients with SIHD and ACS in the setting of medical management or implantation of a coronary artery stent. Balancing the reduction in risk of ongoing ischemic events with hemorrhagic complications presents challenges, as does deciding on duration of therapy. Using a DAPT risk calculator can be helpful to present information to the health care team and the patient, thus encouraging patient-centered treatment decisions.
Patients at increased risk of ischemia, such those with an ACS presentation, multiple myocardial infarcts, extensive CAD, left-ventricular ejection fraction <40%, chronic kidney disease, or diabetes mellitus might benefit from longer DAPT. Conversely, patients with prior bleeding complications, taking oral anticoagulation, with body weight <60 kg, or on chronic steroids or nonsteroidal medications might benefit from shorter duration of DAPT.
Earlier recommendations about the duration of DAPT continue to be refined by ongoing clinical research. Current-generation DESs have improved over first-generation stents; updated guidelines from the AHA and ESC presented in this review are based on new, improved stents.
ASA should almost always be continued upon completion of DAPT or if P2Y12inhibitors are held for surgery.
Last, in patients with mild ischemic stroke or TIA, DAPT therapy, begun within 24 hours and continued for 21 to 28 days, followed by ASA, 81 mg/d, alone indefinitely, can reduce the risk of recurrent stroke.
CORRESPONDENCE
William J. Curry, MD, MS, Departments of Family and Community Medicine and Public Health Sciences, H154, 500 University Drive, Pennsylvania State University College of Medicine, Hershey, PA 17033; wcurry@pennstatehealth.psu.edu.
