2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy

Abstract

Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

“…[13][14][15] Major international guidelines also recommend initiation of at least 12 months of dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor (ticagrelor, prasugrel, or clopidogrel) in patients with NSTEMI who are managed with medical therapy and/or who are treated with revascularization (ie, irrespective of initial treatment strategy), unless there are previous or ongoing contraindications. [13][14][15][16][17][18] Ticagrelor is recommended over clopidogrel for patients with NSTEMI, including those pretreated with clopidogrel (which should be discontinued when ticagrelor is started). Ticagrelor is contraindicated in patients with previous intracranial hemorrhage or ongoing bleeds.…”

Time‐trends and treatment gaps in the antithrombotic management of patients with atrial fibrillation after percutaneous coronary intervention: Insights from the CHUM AF‐STENT Registry

“…10,11 A shift to dual pathway antithrombotic management is also advocated in the 2018 updates of the CCS antiplatelet and atrial fibrillation guidelines. 16,17 The recently published AUGUSTUS trial (apixaban), that also included medically managed ACS patients, also supports the safety advantage of dual pathway therapy over triple therapy. 12 The ENTRUST-PCI AF trial (edoxaban) furtherly reinforced the safety and anti-ischemic efficacy of dual pathway regimens of dual pathway over triple therapy, with no significant difference in ischemic events between the two groups.…”

“…The emergence of dual pathway antithrombotic therapy (anticoagulant plus a single antiplatelet agent) in clinical practice, on the other hand, represents an integration of randomized trial data from PIONEER AF‐PCI (rivaroxaban) and REDUAL (dabigatran) that showed that such a regimen could minimize bleeding risk without a signal for increase in clinical ischemic events . A shift to dual pathway antithrombotic management is also advocated in the 2018 updates of the CCS antiplatelet and atrial fibrillation guidelines . The recently published AUGUSTUS trial (apixaban), that also included medically managed ACS patients, also supports the safety advantage of dual pathway therapy over triple therapy .…”

“…Interventional cardiologists at our center no longer appear to be avoiding DES in AF patients when anticoagulation is indicated. Historically, bare‐metal stents (BMS) had been preferred for many patients requiring OAC because of the shorter DAPT duration required with BMS . More recently, however, the recognition that shorter courses of DAPT (3‐6 months) with second generation DES are likely safe, combined with evidence of a safety advantage for NOAC‐based antithrombotic regimens is likely largely responsible for this observed change in stent choice.…”

“…Historically, bare‐metal stents (BMS) had been preferred for many patients requiring OAC because of the shorter DAPT duration required with BMS . More recently, however, the recognition that shorter courses of DAPT (3‐6 months) with second generation DES are likely safe, combined with evidence of a safety advantage for NOAC‐based antithrombotic regimens is likely largely responsible for this observed change in stent choice. Additionally, recent studies among patients at high risk for bleeding, including those requiring OAC, have demonstrated the superior efficacy and safety of using certain DES platforms compared to BMS when shorter courses of DAPT are necessary .…”