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Dual Antiplatelet Therapy for Long-term Secondary Prevention of Atherosclerotic Cardiovascular Events
Paul P Dobesh1, Shannon W Finks2, Toby C Trujillo3
1University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA.
Insights
Dual antiplatelet therapy (DAPT) after stenting or acute coronary syndrome (ACS) may be extended beyond one year. Decisions on prolonged DAPT should balance ischemic benefits against increased bleeding risks for individual patients.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is standard after percutaneous coronary intervention (PCI) and acute coronary syndrome (ACS).
- Current guidelines recommend 6 months of DAPT after elective drug-eluting stent placement and at least 12 months after ACS.
- The optimal duration of DAPT beyond one year remains unclear, with potential benefits and risks needing careful consideration.
Purpose of the Study:
- To review and analyze data supporting or refuting the use of DAPT beyond one year.
- To examine DAPT duration in patients with ACS and those undergoing PCI with stenting.
Main Methods:
- A comprehensive PubMed search was conducted for relevant articles published within the last 20 years.
- The review focused on studies investigating the role and outcomes of DAPT exceeding 12 months' duration.
Main Results:
- Studies show potential ischemic benefits from prolonging DAPT, but these are population and study design dependent.
- Extended DAPT is associated with an increased risk of bleeding.
- For specific patient groups, such as those with prior myocardial infarction, a reduced dose of ticagrelor (60 mg BID) may be considered after the first year.
Conclusions:
- Prolonging DAPT beyond one year requires individualized assessment of thrombotic and bleeding risks.
- Tailoring DAPT duration and P2Y12 inhibitor choice to the patient's profile, comorbidities, and risk factors is crucial.
- Risk scores, like the DAPT score, can aid in decision-making for optimizing patient outcomes.
Purpose:
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is currently recommended to prevent further ischemic events after percutaneous coronary intervention and acute coronary syndrome (ACS). Guidelines currently recommend a minimum of 6 months after elective drug-eluting stent placement and at least 12 months of DAPT after ACS; however, the benefits of prolonged treatment are unclear. The purpose of this review was to conduct a detailed examination of the data refuting or supporting the use of DAPT beyond 1 year in patients with ACS and in patients receiving percutaneous coronary intervention with stenting.
Methods:
A search of PubMed was performed to identify articles published in the last 20 years that addressed the role of DAPT beyond 12 months' duration.
Findings:
A number of studies have shown ischemic benefits associated with prolonging DAPT beyond 12 months, but this finding is dependent on the patient population studied and the quality of the study design. Many studies also show that longer duration therapy has been associated with increased bleeding risk. In patients with previous myocardial infarction completing at least 1 year of DAPT, continuing DAPT with a reduced dose of ticagrelor 60 mg BID is a regimen to be considered for these patients; in general ACS patients, a reduced dose of 60 mg BID of ticagrelor after the first year of DAPT should be considered; and in the post-percutaneous coronary intervention patients, DAPT beyond 1 year should be considered after careful evaluation of the patient's thrombotic and bleeding risks.
Implications:
The duration of DAPT, and the choice of P2Y12 inhibitor, should be tailored to the individual patient. To optimize patient outcomes, the benefits and risks associated with prolonging DAPT need to be evaluated, considering comorbidities and the presence of bleeding and ischemic risk factors. Despite some limitations, risk scores, such as the DAPT score, are available to help guide decisions for the best approach for each patient.
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