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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Patients with CAD should continue ASA treatment when DAPT is discontinued or completed, unless contraindicated.^13,14

Triple therapy: DAPT + anticoagulant

Given that the US population is aging, there are an increasing number of patients with CAD and atrial fibrillation. Stroke is prevented in patients with atrial fibrillation with anticoagulant therapy; when these patients have stent placement for coronary, carotid, vertebral, or intracranial arterial disease, they need DAPT to prevent stent thrombosis. In the immediate post-stenting period, therefore, patients are often placed on an oral anticoagulant as well as DAPT. Vitamin K antagonists (VKAs) should be discontinued after acute stroke, with individualized resumption of a VKA when clinically appropriate.

As we emphasize throughout this article, there is a balance between bleeding risk and the potential benefits of therapy of the selected anticoagulant/DAPT regimen. These complex patients are best managed in close consultation with Cardiology and Neurology because of their potential risk of 3-fold bleeding.²⁵ The findings of a recent study addressing post-stent placement therapy in patients with nonvalvular atrial fibrillation suggests that the direct oral anticoagulant dabigatran may be preferable to warfarin in this setting, because of the lower risk of bleeding with dabigatran without increased thrombotic risk.²⁶ In this study, 3-drug therapy was used for 1 month, followed by discontinuation of ASA and continuation of 2-drug therapy with the direct oral anticoagulant and the P2Y12 inhibitor for the 6- to 12-month time frame post-stenting (SOR: B).

Consider a PPI to reduce the risk of a GI bleed

Proton-pump inhibitors (PPIs) should be considered for patients treated with DAPT if there is a history of gastrointestinal (GI) bleeding (SOR: A). Although a potential interaction between PPIs and P2Y12 inhibition has been identified in laboratory studies, this has not been supported in clinical studies. Therefore, although warnings exist for concomitant use of clopidogrel and PPIs, a PPI is reasonable for patients who are at increased risk of GI hemorrhage, including those taking warfarin, a corticosteroid, or a nonsteroidal anti-inflammatory drug and those of advanced age (SOR: B). Risks and benefits of clopidogrel and PPIs should be discussed with patients. There is no benefit in using PPIs for low-risk patients. (SOR: A: No benefit).^27,28

Perioperative management with DAPT can be thorny

Perioperative management of DAPT patients who have an indwelling coronary stent and require noncardiac surgery is complicated. Stent thrombosis is a calamity, with ≥50% risk of death. Delaying surgery for at least 4 weeks after placement of a BMS and 6 months after placement of a DES reduces the risk of thrombosis.²⁹

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