ACC/AHA Issue Updated Guidelines on Dual Antiplatelet Therapy in CAD

The American College of Cardiology (ACC) and the American Heart Association (AHA) issued updated guidelines for dual antiplatelet therapy in patients with coronary artery disease (CAD).

The American College of Cardiology (ACC) and the American Heart Association (AHA) issued updated guidelines for dual antiplatelet therapy in patients with coronary artery disease (CAD). 

Dual antiplatelet therapy is a combination of aspirin with a P2Y12 inhibitor such as clopidogrel, prasugrel or ticagrelor. This therapy is prescribed to reduce the risks of future heart attack and coronary stent thrombosis.

RELATED: Study Examines Effects of Switching from Prasugrel to Ticagrelor

The new recommendations are based on data from recent studies regarding the length of time patients with CAD—those with myocardial infarction and those undergoing coronary stent implantation—should be treated with dual antiplatelet therapy. These guidelines impact existing recommendations on duration of dual antiplatelet therapy in 6 guidelines: the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (PCI), the 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, the 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, the 2014 ACC/AHA Guideline for Non-ST-Elevation Acute Coronary Syndromes and the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.

The major concepts and updated recommendations for dual antiplatelet therapy (DAPT) and duration include: 
  • Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, as well as prolongation of DAPT, necessitates a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions about treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and consideration of patient preference. 
  • In general, shorter-duration DAPT can be considered for patients at lower ischemic risk with high bleeding risk, whereas longer-duration DAPT may be reasonable for patients at higher ischemic risk with lower bleeding risk. 
  • Compared with first-generation stents, newer-generation stents have an improved safety profile and lower risk of stent thrombosis. Recommendations in this focused update apply to newer-generation stents. 
  • Updated recommendations for duration of DAPT are now similar for patients with NSTE-ACS and STEMI, as both are part of the spectrum of acute coronary syndrome. 
  • A Class I recommendation (“should be given”) in most clinical settings is made for at least 6–12 months of DAPT (depending on the setting), and a Class IIb recommendation (“may be reasonable”) is made for prolonged DAPT beyond this initial 6- to 12-month period. 
  • In patients for whom the benefit/risk ratio seemingly favors prolonged therapy, the true optimal duration of therapy is unknown. 
  • Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD. 
  • The recommended daily dose of aspirin in patients treated with DAPT is 81mg (range, 75mg to 100mg). 

The updated recommendations also provide guidance on dual antiplatelet therapy after coronary artery bypass grafting and issues about the timing of non-cardiac surgery in patients treated with coronary stent implantation and dual antiplatelet therapy. The timing of surgery and the decision to discontinue dual antiplatelet therapy after stent implantation involve the consideration of the specific procedure and the risks of delaying it, the risks of ischemia and stent thrombosis, and the risk and consequences of bleeding. 

The full guideline titled “2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease” can be found here.

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