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Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention

  • Interventional Cardiology (SR Bailey and T Helmy, Section Editors)
  • Published:
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Abstract

Purpose of review

The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation.

Recent findings

Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3–6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events.

Summary

Clopidogrel is the P2Y12 inhibitor of choice, while more data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.

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Abbreviations

ALPHEUS:

Assessment of Loading With the P2Y12 Inhibitor Ticagrelor or Clopidogrel to Halt Ischemic Events in Patients Undergoing Elective Coronary Stenting

ACS:

Acute coronary syndrome

BARC:

Bleeding Academic Research Consortium

CAPRIE:

Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events

CHARISMA:

Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance

COMMIT:

ClOpidogrel and Metoprolol in Myocardial Infarction Trial

COMPASS:

Cardiovascular Outcomes for People Using Anticoagulation Strategies

CREDO:

Clopidogrel for the Reduction of Events During Observation

CURE:

Clopidogrel in Unstable Angina to Prevent Recurrent Events

DAPT:

Dual antiplatelet

HOST-EXAM:

Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention

MI:

Myocardial infarction

PARIS:

Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients

PCI:

Percutaneous coronary intervention

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

SASSICAIA:

Strategies of Loading With Prasugrel Versus Clopidogrel in PCI-Treated Biomarker Negative Angina

STEMI:

ST-elevation myocardial infarction

THEMIS:

Effect of Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study

TICO:

Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-eluting Stent for Acute Coronary Syndrome

TWILIGHT:

Ticagrelor with Aspirin or Alone in High-Risk Patients after Coronary Intervention

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Author information

Authors and Affiliations

  1. Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada

    Mohammad Alkhalil & Vladimír Džavík

  2. Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK

    Mohammad Alkhalil

  3. Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK

    Mohammad Alkhalil

  4. Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA

    Deepak L. Bhatt

  5. Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Roxana Mehran

  6. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada

    Shamir R. Mehta

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  1. Mohammad Alkhalil
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  3. Deepak L. Bhatt
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  5. Shamir R. Mehta
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Correspondence to Shamir R. Mehta.

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Conflict of Interest

Dr. Deepak L. Bhatt discloses the following relationships - Advisory Board: Bayer, Boehringer Ingelheim, Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Janssen, Level Ex, Medscape Cardiology, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, Regado Biosciences, Stasys; Board of Directors: Boston VA Research Institute, DRS.LINQ (stock options), Society of Cardiovascular Patient Care, TobeSoft; Chair: Inaugural Chair, American Heart Association Quality Oversight Committee; Data Monitoring Committees: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Abbott, Afimmune, Aker Biomarine, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, 89Bio; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), Philips, Svelte; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Merck, Takeda.

Dr. Mehran reports institutional research payments from Abbott, Abiomed, Alleviant Medical, AMPharma, Applied Therapeutics, Arena, AstraZeneca, BAIM, Bayer, Beth Israel Deaconess, Biosensors, Biotronik, Boston Scientific, Bristol-Myers Squibb, CardiaWave, CellAegis, CeloNova, CERC, Chiesi, Concept Medical, CSL Behring, DSI, Duke University, Element Science, Humacyte, Insel Gruppe AG, Janssen, Magenta, Medtronic, Novartis, OrbusNeich, Philips, Vivasure, Zoll; personal fees from Boston Scientific, California Institute for Regenerative Medicine (CIRM), Cine-Med Research, Janssen, WebMD; consulting fees paid to the institution from Idorsia Pharmaceuticals, Medtronic, Novartis, Philips; Equity < 1% in Applied Therapeutics, Elixir Medical, STEL, CONTROLRAD (spouse); Scientific Advisory Board for AMA, ACC (BOT Member), SCAI (Women in Innovations Committee Member), Biosensors (spouse); Faculty CRF (no fee).

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This article is part of the Topical Collection on Interventional Cardiology

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Alkhalil, M., Džavík, V., Bhatt, D.L. et al. Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention. Curr Cardiol Rep 24, 277–293 (2022). https://doi.org/10.1007/s11886-022-01645-0

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