What is the best way to manage dual antiplatelet therapy in patients with coronary artery disease?

These guidelines summarize a complex set of recommendations for the use of dual antiplatelet therapy. In general, clopidogrel is the recommended drug for most indications, longer duration therapy is more likely to provide net benefit in patients following an episode of acute coronary syndrome (ACS), or in patients with stable ischemic heart disease (SIHD) who undergo percutaneous coronary intervention and are at low risk of bleeding. (LOE = 1a)

Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. Circulation 2016;134(10):e123-155.  [PMID:27026020]

Practice guideline

Foundation

Various (guideline)

This is an attempt to simplify the American College of Cardiology/American Heart Association guidelines but they remain quite complex, with many recommendations. Although the guideline panel had extensive ties to industry, more than half were not conflicted and the panel chair did not have any relevant conflicts. This is a focused update to previous guidelines that tries to make sense of 11 recent randomized controlled trials that compared different durations and formulations of dual antiplatelet therapy (DAPT) in patients with ACS or SIHD. Patients are considered to have SIHD when it has been at least 1 year since their last episode of ACS. An algorithm provides an overview of the recommendations, and is summarized here. All patients are assumed to be taking 75 mg to 100 mg aspirin once daily, so the recommendations focus on the P2Y12 inhibitor. For patients with acute or recent ACS, including ST-segment elevation myocardial infarction (STEMI) or non-ST elevation ACS, the choice of DAPT regimen depends on their treatment. If medical therapy, at least 12 months of clopidogrel or ticagrelor; if lytic therapy for a STEMI, at least 14 days and ideally 12 months of clopidogrel; if percutaneous coronary intervention with bare metal or drug-eluting stent, then at least 12 months of DAPT; and if coronary artery bypass graft, 1 year of DAPT is recommended. For patients with SIHD, no DAPT is recommended for those without myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft in the past 12 months. For patients with SIHD and a coronary artery bypass graft in the past 12 months, 1 year of DAPT "may be reasonable." Finally, for those who have undergone percutaneous coronary intervention, at least 1 month of clopidogrel is recommended following bare metal stent and 6 months of clopidogrel is recommended after drug-eluting stent. If the patient has no high risk of bleeding and no significant bleeding while using DAPT, longer term DAPT "may be reasonable." Of course, when something "may be reasonble," that also means it "may not be reasonable." Longer duration of therapy is a trade-off between a decreased risk of stent thrombosis and an increased risk of major bleeding, so this choice requires judgment and shared decision-making. Patients with a history of gastrointestinal bleeding or a risk for bleeding should consider taking a proton pump inhibitor. Regarding choice of P2Y12 inhibitor, ticagrelor and prasugrel generally result in a small reduction in ischemic events and re-thrombosis that must be balanced against higher bleeding risks and cost: In the United States, ticagrelor is $350 per month, prasugrel is $430 per month, and clopidogrel is $7 per month (www.goodrx.com, 2/28/17).