The art of delivering evidence-based dual antiplatelet therapy

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Applied Evidence

The art of delivering evidence-based dual antiplatelet therapy

J Fam Pract. 2018 December;67(12):758-766

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References

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Ticagrelor. Unlike clopidogrel and prasugrel, ticagrelor is a direct oral, reversible-binding P2Y12 inhibitor. Peak serum concentration is reached within 2 to 3 hours.¹⁷ Indications are ACS or a history of MI, and those with ACS undergoing stent implantation. Ticagrelor was superior to clopidogrel in reducing the risk of death from vascular causes, MI, and stroke, and superior to clopidogrel in reducing the risk of stent thrombosis. There was no increase in the overall major bleeding rate and a decrease in fatal bleeding events compared to clopidogrel. Adverse effects unique to ticagrelor include dyspnea and, in patients with bradydysrhythmias, asymptomatic ventricular pauses. Both effects tend to resolve with continued treatment. This P2Y12 inhibitor should be avoided in patients with severe liver disease.

Loading and maintenance doses of the 3 P2Y12 inhibitors are provided in TABLE 1.^13,14

When—and when not—to initiate DAPT

Treatment recommendations for DAPT originated in the 2016 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease¹⁴ and in the 2017 European Society of Cardiology (ESC) focused update on dual antiplatelet therapy in coronary artery disease.¹³ Although these guidelines differ slightly, the overall approach they present is similar, with an emphasis on limiting bleeding while preventing stent thrombosis.

Stable ischemic heart disease (SIHD) is defined as confirmed obstructive CAD without either ACS or a history of PCI in the past year.¹⁸ Patients with SIHD but without a history of PCI or recent coronary artery bypass grafting (CABG) receive no benefit from DAPT (Strength of recommendation [SOR]: A).¹⁹ (See TABLE 2 for definitions of SOR and corresponding levels of evidence.)

For patients who have undergone BMS placement, minimum DAPT with clopidogrel is 1 month (SOR: A) and, if there is no significant bleeding on DAPT and no high risk of bleeding (ie, no prior bleeding while taking DAPT, coagulopathy, or oral anticoagulant use), continuation of ASA and clopidogrel beyond 1 month might be reasonable (SOR: B).

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