Dual Antiplatelet or Dual Antithrombotic Therapy for Secondary Prevention in High-Risk Patients with Stable Coronary Artery Disease?

Steen D Kristensen,Wael Sumaya,Robert F Storey,Tobias Geisler

doi:10.1055/s-0039-1679903

Abstract

Antithrombotic treatment is a key component of secondary prevention following acute coronary syndromes (ACS). Although dual antiplatelet therapy is standard therapy post-ACS, duration of treatment is the subject of ongoing debate. Prolonged dual antiplatelet therapy in high-risk patients with history of myocardial infarction reduced the risk of recurrent myocardial infarction, stroke or cardiovascular death. Similarly, in patients with stable coronary artery disease, two-thirds of whom had a history of myocardial infarction, dual antithrombotic therapy with very-low-dose rivaroxaban and aspirin also resulted in improved ischaemic outcomes. In the absence of head-to-head comparison, choosing the most appropriate treatment strategy can be challenging, particularly when it comes to balancing the risks of ischaemia and bleeding. We aim to review the evidence for currently available antithrombotic treatments and provide a practical algorithm to aid the decision-making process.

Highlights

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor forms the backbone of secondary prevention following acute coronary syndromes (ACS).[1,2]
In the COMPASS trial,[5] dual antithrombotic therapy (DATT) with an anticoagulant and aspirin resulted in a significant reduction in major CV events in high-risk stable coronary artery disease (CAD) patients, two-thirds of whom had a history of myocardial infarction (MI)
DATT resulted in a significant reduction in major adverse cardiovascular event (MACE) compared with aspirin (4.1% vs. 5.4%, respectively, p < 0.001), including a reduction in CV death (1.7% vs. 2.2%, p 1⁄4 0.02) and a substantial reduction in ischaemic stroke (0.7% vs. 1.4%, p < 0.001)

Summary

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor forms the backbone of secondary prevention following acute coronary syndromes (ACS).[1,2] Twelve months’ DAPT post-ACS is well established but evidence to support prolonged intensive therapy in high-risk patients following myocardial infarction (MI) continues to emerge. Multiple landmark clinical trials have established a definitive advantage for combining aspirin and a P2Y12 inhibitor for approximately 12 months post-ACS.[7,8,9,13] Prasugrel and ticagrelor offer more rapid, potent and consistent P2Y12 inhibition compared with clopidogrel. These properties have translated into improved outcomes.8,9 ►Table 1 summarizes the pharmacodynamics of each of these agents and provides a summary of appropriate use post-ACS. Should not be used in patients with history of intracranial haemorrhage or those taking strong CYP3A inducers or inhibitors

May be used 2 d post-thrombolysis in STEMI patients undergoing PCI39

Findings

Conclusion