Abstract
To prevent recurrent ischaemic events, dual antiplatelet therapy (DAPT) is the standard of care after percutaneous coronary intervention and in the treatment of acute coronary syndrome. Recent evidence supports an adjusted DAPT duration in selected patients.The current paper aims to encourage cardiologists to actively search for patients benefiting from either shorter or prolonged duration DAPT and proposes an algorithm to identify patients who are likely to benefit from such an alternative strategy.Individualised DAPT duration should be considered in high-risk anatomic and/or clinical subgroups or in patients at increased haemorrhagic risk with low ischaemic risk. Both thrombotic and haemorrhagic risk should be assessed in all patients. In patients undergoing percutaneous coronary intervention, the interventional cardiologist could advise on the minimal duration of DAPT. However, in contrast to the minimum duration of DAPT for stent thrombosis prevention, longer duration DAPT is aimed at prevention of spontaneous myocardial infarction, and not at stent thrombosis, and thus the key to success is to treat the patient’s overall thrombotic risk.The advice on the duration of DAPT must be documented in the patient’s records and communicated with the treating physician and general practitioner. DAPT duration should be reassessed at least on a yearly basis.
Highlights
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid in combination with a P2Y12 inhibitor is the standard of care after an acute coronary syndrome (ACS) and after percutaneous coronary intervention (PCI), to prevent recurrent ischaemic events such as stent thrombosis
Clopidogrel is first choice in PCI patients with stable coronary artery disease, whereas the stronger P2Y12 inhibitors ticagrelor and prasugrel are mainly used in the ACS setting
As the risk of late stent thrombosis is less of a concern with second-generation drug-eluting stents (DES), prolonged dual antiplatelet therapy (DAPT) is more aimed at preventing myocardial infarction (MI) not related to the implanted stent
Summary
Dual antiplatelet therapy (DAPT) with acetylsalicylic acid in combination with a P2Y12 inhibitor is the standard of care after an acute coronary syndrome (ACS) and after percutaneous coronary intervention (PCI), to prevent recurrent ischaemic events such as stent thrombosis. First-generation DES were associated with a slight increase in stent thrombosis, which is the most feared complication of coronary stenting due to its very high mortality rates. Since the introduction of second-generation DES, together with the use of stronger P2Y12 inhibitors, rates of stent thrombosis have decreased by approximately 50% [3]. As the risk of late stent thrombosis is less of a concern with second-generation DES, prolonged DAPT is more aimed at preventing (recurrent) myocardial infarction (MI) not related to the implanted stent. The REDUCE trial is addressing the issue of reduced DAPT duration in ACS patients This physician-initiated, multicentre trial randomises 1,500 ACS patients treated with the COMBO stent to 3 vs 12 months of DAPT [16]
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Schedule a callMore From: Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation
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