Dual Antiplatelet Therapy Challenges in Complex Clinical Scenarios

Abstract

The symposium was a practical, case-based discussion in which four panellists each presented a real and challenging case regarding dual antiplatelet therapy (DAPT) strategy. The audience and other panel members were invited to give their thoughts on the difficult decisions that arose during treatment. Case 1, presented by Dr Chevalier, was a man with multivessel disease, enrolled in the Discovery 1TO3 trial.1 He received staged treatment with three stents; strut coverage was evaluated with optical frequency domain imaging (OFDI). Four days after the staged percutaneous coronary intervention (PCI), the patient suffered a Bleeding Academic Research Consortium (BARC) Type 3a gastric bleeding event and the gastroenterologist requested that the DAPT be stopped. Dr Vranckx presented Case 2, in which a man, aged 84 years, presented 5 hours after myocardial infarction. He had a bifurcation lesion and was treated with a two-stent technique. Bleeding and ischaemic risk scores varied according to the risk scoring system used, but overall this patient had a high bleeding risk (HBR) and reasonable ischaemic risk. Treatment had to balance the two risks. Case 3, presented by Dr Cuisset, was a 62-year-old male with chronic coronary artery disease (CAD), alcohol abuse, and Type 2 diabetes mellitus with poor adherence to metformin. The patient had good haemoglobin levels and renal function, and moderate liver abnormalities. He had thrombocytopenia and stable angina with prior documentation of ischaemia under stress. There was no significant lesion on the left anterior descending artery (LAD) or left coronary artery, but a 60–70% stenosis of the mid-right coronary artery (RCA). He was likely to be nonadherent to antiplatelet therapy. Dr Colombo presented the fourth case, in which a 73-year-old male had a large thoracoabdominal aortic aneurysm and had been referred from vascular surgeons. He had standard risk factors for CAD, reasonable ejection fraction (EF), and no significant valvular disease. Preoperative coronary angiography showed a noncritical stenotic lesion on RCA, a 90% stenotic lesion mid-left circumflex artery (LCX), and total occlusion of LAD. PCI ahead of vascular surgery could involve one, two, or three vessels.