Lights and shadows of long-term dual antiplatelet therapy in “real life” clinical scenarios
- 105 Downloads
Dual antiplatelet therapy (DAPT) is a cornerstone of treatment for patients with acute coronary syndromes (ACS). Mounting evidences have opened the debate about the optimal DAPT duration. Considering the ACS-pathophysiology, the most recent guidelines recommend DAPT in all ACS patients for at least 12 months unless there are contraindications such as excessive risk of bleeding. Thus, it can be considered acceptable earlier discontinuation if the risk of morbidity from bleeding outweighs the anticipated benefit. On the other hand, several studies have clearly indicated that a significant burden of platelet related-events, such as stroke and new ACS might occur after this period, suggesting that potential benefits might derive by prolonging DAPT beyond 12 months (Long DAPT). Indeed, although current guidelines give some indications about patients eligible for Long DAPT, they do not embrace several real-life clinical scenarios. Thus, in such scenarios, how to decide whether a patient is eligible for Long DAPT or not might be still challenging for clinicians. This position paper presents and discusses various “real-life” clinical scenarios in ACS patients, in order to propose several possible recommendations to overcome guidelines potential limitations.
KeywordsAcute coronary syndrome Antiplatelets DAPT Long-term DAPT Patient management
Campania Study Group Faculty
Alessandro Bellis (Napoli), Gennaro Bellizzi (Ariano Irpino), Renatomaria Bianchi (Napoli), Giulio Bonzani (Napoli), Biagio Bosco (S.M. Capua Vetere), Gennaro Caiazzo (Aversa), Paolo Calabrò (Napoli), Luigi Caliendo (Nola),Paolo Capogrosso (Napoli), Nicola Capuano (Nocera Inferiore), Pio Caso (Napoli), Quirino Ciampi (Benevento), Giovanni Cimmino (Napoli), Ersilia Cipolletta (Giugliano), Plinio Cirillo (Napoli), Rosangela Cocchia (Nola), Antonino Coppola (Sorrento), Gregorio Covino (Napoli), Giovanni D’Angelo (Eboli), Giovanni De Caro (C/Mare di Stabia), Luigi Di Lorenzo (Sessa A.), Giovanni Esposito (Napoli), Nicolino Esposito (Napoli), Rosario Farina (Salerno), Dario Formigli (Benevento), Gennaro Galasso (Salerno), Paolo Golino (Caserta), Luigi Irace (Napoli), Tonino Lanzillo (Avellino), Raffaele Marcheggiano (Sessa A.), Franco Mascia (Caserta), Ciro Mauro (Napoli), Raffaele Merenda (Napoli), Giovanni Napolitano (Giugliano), Fabio Pastore (Eboli), Francesco Piemonte (Frattamaggiore), Orlando Piro (Napoli), Federico Piscione (Salerno), Raffaele Sangiuolo (Napoli), Aniello Sansone (Ischia), Marino Scherillo (Benevento), Girolamo Sibilio (Pozzuoli), Bruno Trimarco (Napoli), Bernardino Tuccillo (Napoli), Alfredo Vetrano (Caserta), Bruno Villari (Benevento).
Dario Formigli (Benevento), Plinio Cirillo (Napoli).
All authors contributed to (1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data, (2) drafting of the article or revising it critically for important intellectual content, and (3) final approval of the version to be published. MS, PC, and DF are the coordinators of the study group.
Compliance with ethical standards
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
- 4.Roffi M, Patrono C, Collet JP, Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (2015) ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 37(3):267–315CrossRefPubMedGoogle Scholar
- 5.Windecker S, Kolh P, Alfonso F et al (2014) 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 35(37):2541–2619CrossRefPubMedGoogle Scholar
- 7.Valgimigli M, Bueno H, Byrne RA et al (2017) 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. https://doi.org/10.1093/eurheartj/ehx419 CrossRefPubMedPubMedCentralGoogle Scholar
- 8.Ibanez B, James S, Agewall S et al (2017) 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. https://doi.org/10.1093/eurheartj/ehx393 CrossRefPubMedGoogle Scholar
- 21.Bittl JA, Baber U, Bradley SM, Wijeysundera DN (2016) Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 68(10):1116–1139CrossRefPubMedGoogle Scholar
- 29.Fitch K (2001) The RandUCLA appropriateness method user’s manual. Rand, Santa MonicaGoogle Scholar
- 30.Piepoli MF, Hoes AW, Agewall S, Authors/Task Force Members (2016) European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J 37(29):2315–2381CrossRefPubMedPubMedCentralGoogle Scholar
- 32.Costa F, van Klaveren D, James S et al (2017) Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 389:1025–1034CrossRefPubMedGoogle Scholar
- 35.Rossini R, Oltrona Visconti L et al (2015) Italian Society of Invasive Cardiology (SICI-GISE); National Association of Hospital Cardiologists (ANMCO); Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR); Italian Society of General Practitioner (SIMG): a multidisciplinary consensus document on follow-up strategies for patients treated with percutaneous coronary intervention. Catheter Cardiovasc Interv 85(5):E129–E139CrossRefPubMedGoogle Scholar
- 36.Levine GN, Bates ER, Blankenship JC et al (2011) 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 124(23):2574–2609CrossRefPubMedGoogle Scholar
- 37.Levine GN, Bates ER, Blankenship JC et al (2016) 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 87(6):1001–1019CrossRefPubMedGoogle Scholar
- 46.Levine GN, Bates ER, Bittl JA et al (2016) 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 68(10):1082–1115CrossRefPubMedGoogle Scholar
- 56.Onuma Y, Sotomi Y, Shiomi H et al (2016) Two-year clinical, angiographic, and serial optical coherence tomographic follow-up after implantation of an everolimus-eluting bioresorbable scaffold and an everolimus-eluting metallic stent: insights from the randomised ABSORB Japan trial. EuroIntervention 12(9):1090–1101CrossRefPubMedGoogle Scholar
- 57.Serruys PW, Chevalier B, Sotomi Y et al (2016 Nov) Comparison of an everolimus-eluting bioresorbable scaffold with an everolimus-eluting metallic stent for the treatment of coronary artery stenosis (ABSORB II): a 3 year, randomised, controlled, single-blind, multicentre clinical trial. Lancet 19(10059):2479–2491 388(CrossRefGoogle Scholar
- 60.Bonaca MP, Goto S, Bhatt DL et al (2016) Prevention of stroke with Ticagrelor in patients with prior myocardial infarction: insights from PEGASUS-TIMI 54 (prevention of cardiovascular events in patients with prior heart attack using Ticagrelor compared to placebo on a background of aspirin-thrombolysis in myocardial infarction 54). Circulation 134(12):861–871CrossRefPubMedGoogle Scholar