2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease

Bates, Eric R.; Bittl, John A.; Fihn, Stephan D.; Granger, Christopher B.; Lange, Richard A.; Mack, Michael J.; Mauri, Laura; Mehran, Roxana; Mukherjee, Debabrata; Newby, L. Kristin; O’Gara, Patrick T.; Sabatine, Marc S.; Smith, Peter K.; Smith, Sidney C.; Halperin, Jonathan L.; Levine, Glenn N.; Al‐Khatib, Sana M.; Birtcher, Kim K.; Bozkurt, Biykem; Brindis, Ralph G.; Cigarroa, Joaquin E.; Curtis, Lesley H.; Fleisher, Lee A.; Gentile, Federico; Gidding, Samuel S.; Hlatky, Mark A.; Ikonomidis, John S.; Joglar, José A.; Pressler, Susan J.; Wijeysundera, Duminda N.

doi:10.1016/j.jtcvs.2016.07.044

Cited by 361 publications

(322 citation statements)

References 163 publications

(244 reference statements)

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“…Due to significantly higher rates of bleeding (as compared with clopidogrel), there was no net benefit of prasugrel therapy in those ≥75 years of age and those <60 kg, and there was net harm (including increased risk of intracranial hemorrhage) in those with prior stroke or transient ischemic attack (TIA) [28]. Thus, the current guidelines support the preferential use of ticagrelor over clopidogrel in patients with ACS after coronary stent implantation or medical therapy alone for maintenance P2Y12 inhibitor therapy (Class IIa) and prasugrel over clopidogrel after coronary stent implantation among those not at high risk for bleeding complications and who do not have a history of stroke or TIA (Class IIa) [29].…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Sharma

Agrawal

Garg

et al. 2017

Cathet Cardio Intervent

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Objective To evaluate the long term efficacy and safety of long duration DAPT (L‐DAPT) compared to short duration DAPT (S‐DAPT) after drug‐eluting stent (DES) implantation. Methods We searched Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) to identify randomized controlled trials (RCTs) assessing the clinical impact of L‐DAPT versus S‐DAPT after DES and have mean follow up period of at least 2 years or longer. Primary end point was stent thrombosis (ST). Secondary endpoints were all‐cause mortality, cardiac mortality, myocardial infarction (MI), target vessel revascularization (TVR), thrombolysis in myocardial infarction (TIMI) major bleeding and stroke. Event rates were compared using a random effects model. Results We identified five RCTs in which 19,760 patients were randomized to S‐DAPT (N = 9,810) and L‐DAPT (n = 9,950), respectively. Compared with L‐DAPT, S‐DAPT was associated with higher rate of MI (odds ratio [OR] 1.48, 95% confidence interval [CI] [1.04, 2.10]). There were no significant differences between S‐DAPT and L‐DAPT in terms of all cause mortality, cardiac mortality, ST, TVR or stroke (OR 0.90, 95% CI [0.73, 1.12]; OR 1.02, 95% CI [0.80, 1.30]; OR 1.59, 95% CI [0.77, 3.27]; OR 0.87 95% CI [0.67, 1.14]; and OR 1.08 95% CI [0.81, 1.46], respectively). However, rate of TIMI major bleeding was significantly lower with S‐DAPT compared to L‐DAPT (OR 0.64, 95% CI [0.41, 0.99]). Conclusions In the present analysis of RCTs with longer follow up (2 years or longer), S‐DAPT compared with L‐DAPT, was associated with higher rate of MI and lower rate of major bleeding without any significant difference in the rates of all cause mortality, cardiac mortality, ST, TVR, and stroke.

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Section: Resultsmentioning

confidence: 99%

“…Conversely, older age contributes to a lower (less favorable) DAPT score [29,[32][33] Additional factors that may need to be considered are stent type/generation, drug availability, and patient preference. Newer-generation DES have a lower risk of stent thrombosis and appear to require a shorter minimum duration of DAPT [4,6,7,34,35].…”

Section: Resultsmentioning

confidence: 99%

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Sharma

Agrawal

Garg

et al. 2017

Cathet Cardio Intervent

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“…A substudy of patients who underwent CABG in the PLATO study, identified a significant reduction in cardiovascular death and total mortality with ticagrelor use as compared with clopidogrel administration, without any difference in CABG related major bleeding [10]. A most recent comprehensive review of the data including both randomised and observational data by the ACC/AHA writing group focussed on duration of DAPT therapy, endorsed therapy with DAPT in patients at hospital discharge following CABG [20].…”

Section: Accepted M Manuscriptmentioning

confidence: 99%

The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Anastasius

Lau

Hyun

et al. 2017

International Journal of Cardiology

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“…Based on their findings, the authors conclude that surgery following DES-PCI may be safely considered sooner than is recommended in current guidelines (5,6). Before embracing this change, it should be highlighted that the majority of surgical procedures undertaken in the study were classified as low risk (>70%) and the number of clinical events observed beyond one month was low, limiting the statistical power of the study.…”

Section: "Dear Colleague This 68 Year Old Diabetic Lady Recently Undmentioning

confidence: 97%

Non-cardiac surgery following drug-eluting coronary stent implantation—a question of timing?

2017

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"Dear colleague, this 68 year old diabetic lady recently underwent percutaneous coronary intervention with drug eluting stents. Unfortunately, she now requires hip replacement surgery. I would be grateful for your advice regarding the optimal timing of surgery …"This clinical scenario will be familiar to many involved in the management of patients undergoing non-cardiac surgery. Observational data indicate that between 5% and 35% of patients receiving a drug eluting stent (DES) undergo non-cardiac surgery within 1-2 years of their index percutaneous coronary intervention (PCI). Within this cohort, retrospective observational studies report an overall incidence of peri-operative death or major adverse cardiac events of 2-9%, with the greatest risk when surgery is performed early after stent implantation (1-4). Based on these data, the American College of Cardiology and American Heart Association focused update on duration of dual antiplatelet therapy in patients with coronary artery disease (5) recommends that non-cardiac surgery should be delayed for at least three (class IIb recommendation), but ideally for 6 months (class IIa recommendation), while the most recent European Society of Cardiology guidelines recommend delaying surgery for 6 months following DES implantation (6).Besides their retrospective observational design, major limitations of previous studies have been the lack of a meaningful comparator or control population and the absence of detailed data on peri-operative antiplatelet use. Without these, it remains unclear to what degree the observed rate of peri-operative cardiac events is attributable to the presence of a DES, existing ischaemic heart disease, premature interruption of dual antiplatelet therapy, or surgical factors such as the urgency, type or magnitude of surgery undertaken. A recent study published in the Journal of the American College of Cardiology goes some way towards addressing these limitations and provides further insight into the relationship between the timing of surgery and peri-operative cardiac risk.Egholm and colleagues undertook a retrospective data linkage study using the Western Denmark Heart and Danish National Patient Registries between 2005 and 2012 to identify 4,303 patients who underwent surgery within 12 months of DES implantation, and 20,032 patients without known ischaemic heart disease who underwent similar surgical procedures (7). Clinical outcomes at 30 days (myocardial infarction, cardiac death and all cause mortality) for each DES-PCI patient were compared with up to five control patients matched for age, sex and type of operation. Within the PCI cohort, use of first generation DES was high (60%) with just over half of the patients (56%) undergoing stent implantation for an acute coronary syndrome.Consistent with previous studies (2,4), surgery performed within 1 month of DES implantation, emergency surgery, Editorial

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2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease

Cited by 361 publications

References 163 publications

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

Duration of dual antiplatelet therapy following drug‐eluting stent implantation: A systemic review and meta‐analysis of randomized controlled trials with longer follow up

The underutilisation of dual antiplatelet therapy in acute coronary syndrome

Non-cardiac surgery following drug-eluting coronary stent implantation—a question of timing?

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