Dual antiplatelet therapy after acute coronary syndrome or percutaneous coronary intervention: with what and for how long?

Abstract

Thrombotic complications following coronary interventions (PCI) used to be frequent specifically in acute coronary syndrome (ACS) patients. In recent years complication rates have significantly fallen due to improved stent technology, catheterisation techniques and intravascular visualisation. Therefore, the shortest necessary duration of dual antiplatelet therapy (DAPT) comprising aspirin and a P2Y12 inhibitor is constantly the subject of scientific investigations in order to avoid bleeding complications without allowing ischemic complications to occur. ADAPT duration of 12months after PCI and ACS was accepted as astandard. Meanwhile ahighly individualized approach in terms of therapy duration and choice of drugs that takes the patient's individual bleeding and ischemic risk into account is being practised. Prolonged DAPT (>12months) is currently recommended for patients post myocardial infarction with alow bleeding risk, at high ischemic risk due to coronary triple vessel disease, following ahigh risk coronary intervention with an unsatisfactory result or apersonal history of prior stent thrombosis. Alternatively, instead of prolonged DAPT, dual-pathway antithrombotic therapy of aspirin plus rivaroxaban (2.5 mg bid) is recommended to prevent future strokes, critical limb ischemia and to reduce mortality in cases with multiregional atherosclerosis. In the meantime, reduced-duration DAPT of 3-6months is being recommended for most patients. Recent data show that in patients with ahigh bleeding risk, aDAPT treatment period of 4weeks may be sufficient with amarkedly reduced rate of bleeding and without evidence for more ischemic events. Following the early termination of DAPT, continuing antithrombotic monotherapy with the P2Y12 inhibitor ticagrelor may be indicated to prevent further ischemic events without the risk of bleeding complications comparable to DAPT.