Dual antiplatelet therapy after coronary stent implantation: Individualizing the optimal duration

Abstract

Dual antiplatelet therapy (DAPT) with a P2Y receptor antagonist in addition to aspirin is the antiplatelet treatment of choice in patients undergoing percutaneous coronary intervention. Despite DAPT being one of the most widely investigated treatment strategies in the cardiology field, its optimal duration after coronary stenting remains controversial. The balance between the possible benefit of preventing a thrombotic event and the risk of suffering a bleeding complication due to maintenance of therapy is of critical relevance to determine the duration of DAPT in a given patient. Indeed, extended DAPT is associated with a reduction in non-fatal ischemic outcomes, at the cost of increasing the risk of bleeding events. Of note, several factors related to the patient, the procedure, or the device implanted may influence the ischemic and/or bleeding risk profiles of a given patient. Therefore, it is reasonable to recommend that the decision on DAPT duration should be individualized on a case-to-case basis. This review aims to provide a comprehensive overview of the current status of knowledge on duration of DAPT after coronary stenting, focusing on the evidence provided mainly by randomized clinical trials, as well as to discuss the factors that may influence the individual ischemic and bleeding risk profiles for a given patient, and whether the use of risk scores may inform the decision-making process for determining DAPT duration.

Antithrombotic Therapy After Transcatheter Aortic Valve Implantation

“…This strategy is empirical and based, first and foremost, on current recommendations for patients undergoing percutaneous coronary interventions. 25 Further, anatomopathological analyses have suggested that neointimal tissue invasion and full endothelialisation of the valve stent frame occur approximately 3 months after the procedure, with a decrease in thromboembolic events thereafter, which might support this antithrombotic strategy. 36 Recent evidence, however, has questioned the usefulness and safety of DAPT over SAPT with aspirin.…”

“…Regardless, a period of dual antiplatelet therapy (DAPT) after coronary revascularisation is mandatory, which has also evident implications in the decision-making process of selecting the antithrombotic treatment regimen after TAVI. 25,26 The spectrum of bioprosthetic leaflet thrombosis comprises subclinical imaging findings, such as early reduced leaflet motion and hypoattenuated leaflet thickening, to clinically apparent valve thrombosis with elevated gradients and clinical manifestations (i.e. heart failure, valve dysfunction and stroke or systemic embolisms).…”

Incidence and risk factors for major bleeding among patients undergoing percutaneous coronary intervention: findings from the Norwegian coronary stent trial (NORSTENT)

“…Investigators of the SECURITY RCT report a 12-month cumulative incidence of BARC 3 or 5 (i.e., CABG related bleeding excluded) major bleeding after DAPT with clopidogrel of 1.1% [18]. Other explanatory RCTs report a 12-month cumulative incidence in the range 0.5-1.5%, with differing bleeding definitions [2,17], while the 12-month cumulative incidence of Thrombolysis in Myocardial Infarction (TIMI) major bleeding was around 0.7% (1.3% if minor bleeding is included) in the derivation cohort for the PRECISE-DAPT score; bleeding events in the first seven days were excluded [3]. In the DAPT RCT, 2.7% of patients were excluded before randomization, due to a GUSTO major bleeding during the initial 12 months [19].…”

“…Dual antiplatelet therapy (DAPT) is mandatory after percutaneous coronary intervention (PCI) with stent implantation in order to prevent ischemic events [1]. The optimal duration of DAPT, however, is debated [2]. The risk of ischemic events must be balanced against the risk of major bleeding imposed by the antithrombotic therapy.…”

Antithrombotic therapy after percutaneous revascularization in patients on chronic oral anticoagulation treatment

“…Chronic oral anticoagulation (OAC) is superior to antiplatelet therapy (whether monotherapy or dual therapy) when it comes to the prevalence of thromboembolic complications (stroke and systemic embolism) of AF, 6,7 while the dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y 12 receptor inhibitor (P2YI 12 ) is the antithrombotic therapy of choice to prevent atherothrombotic ischemic events (myocardial infarction and stent thrombosis) in patients who undergo PCI (in the context, or not, of an ACS). 8,9 When both situations occur picking the antithrombotic therapy becomes a clinical issue because it is well-known that the easiest choice, that is, the use of triple antithrombotic therapy (TAT plus OAC and dual antiplatelet therapy) increases the risk of major hemorrhages at least 2 to 3-fold compared to any other antithrombotic regimens, whether dual antiplatelet therapy or dual antithrombotic therapy (DAT plus OAC and one antiplatelet drug). 10,12 Therefore, controversy arises on whether or not using TAT due to the increase of hemorrhagic complications and the possible increase of ischemic events when using less aggressive therapies like DAT.…”