Departments of Family and Community Medicine and Public Health Sciences (Dr. William J. Curry), Department of Medicine, Division of Cardiology (Dr. Chambers), Department of Family and Community Medicine (Dr. Gwendolyn W. Curry), Pennsylvania State University College of Medicine, Hershey; Department of Family and Community Medicine, Eglin Air Force Base Regional Hospital, Fla (Dr. Elizabeth W. Curry). wcurry@pennstatehealth.psu.edu
The authors reported no potential conflict of interest relevant to this article.
When lytic interventions are employed in STEMI, DAPT with clopidogrel—for a minimum of 14 days and, ideally, for 12 months—should be considered. Without high risk of bleeding, or significant bleeding on DAPT, continuing DAPT for >12 months might be reasonable (SOR: A).
TABLE 3,13,14 adapted from 2016 ACC/AHA14 and 2017 ESC13 guidelines, provides recommendations about agents and duration of therapy in the management of patients with CAD.
How long should you give DAPT?
Balancing the hemorrhagic complications of DAPT against its benefits is challenging. The use of risk scores to guide duration of DAPT may be considered (SOR: B).
The PRECISE-DAPT score21 is used at the time of coronary artery stenting to guide treatment duration. The scoring algorithm incorporates hemoglobin level, leukocyte count, age, creatinine clearance and prior bleeding to create a composite score on a 100-point scale.22 (The algorithm can be found at www.precisedaptscore.com/predapt/webcalculator.html.) If the composite is <25 points, the number needed to treat to prevent an ischemic event is 65, and standard or long-term DAPT (12 to 24 months) is recommended. When the PRECISE-DAPT score is ≥25, the number needed to harm with a hemorrhagic event is 38, and a shorter duration of therapy (3 to 6 months) is recommended.
Ticagrelor should be avoided in patients with severe liver disease.
The DAPT score,23 available from the American College of Cardiology24 (http://tools.acc.org/DAPTriskapp/#!/content/calculator) is a risk calculator for use after 12 months of DAPT in the absence of complications. Age, cigarette use, diabetes, current or previous MI, presence of congestive heart disease, and type and location of stent all factor into calculating the risk score. DAPT scores range from -2 to 10. A score ≥2 suggests less bleeding risk, with a recommendation to consider longer treatment (≤30 months); a score <2 leads to a recommendation to adhere to standard treatment duration of 12 months.
