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DAPT remains a mainstay after PCI
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Dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor is the main medical therapy for optimizing stent-related outcomes after PCI, concluded a review published today in JAMA.
For the study, Emmanouil S. Brilakis, MD, PhD, and fellow researchers from the University of Texas Southwestern Medical Center at Dallas conducted a review of 91 publications (from the 6,852 retrieved) from 2000 to February 2013 that assessed optimal medical therapy after PCI.
They found that DAPT with aspirin and a P2Y12 inhibitor (eg, ticlopidine, clopidogrel [Plavix, Sanofi-Aventis], prasugrel [Effient, Daiichi Sankyo/Eli Lilly] and ticagrelor [Brilinta, AstraZeneca]) reduced the risk of stent thrombosis and subsequent CV events following PCI (number needed to treat, 33-53).
According to their findings, aspirin should be continued indefinitely and low doses (75-100 mg daily, usually 81 mg) is preferred over higher doses because of similar efficacy and higher bleeding risk with higher doses; this is a class IIA recommendation after PCI. A P2Y12 inhibitor should also be given for 12 months after PCI, unless the patient is at high risk for bleeding, although ongoing studies may result in a change to this recommendation.
Emmanouil S. Brilakis
Further, patients with ACS should take prasugrel and ticagrelor for additional reduction of CV ischemic events compared with clopidogrel, but these drugs are associated with higher bleeding risk, researchers said. If possible, noncardiac surgery should be delayed until 12 months after coronary stenting.
Additionally, patients receiving coronary stents who require warfarin are at high risk for bleeding if they also receive DAPT. It may also be better to not give aspirin to this group of patients, researchers wrote.
Finally, physicians should not routinely conduct routine platelet function or genetic testing to tailor antiplatelet therapy after PCI.
“Patients who receive coronary stents and also require oral anticoagulation for another indication (such as atrial fibrillation) may be best treated with bare-metal stents followed by 1 month of DAPT,” Brilakis, who is an Editorial Board member of Cardiology Today’s Intervention, and colleagues said. “If such patients receive DES, use of warfarin and clopidogrel without aspirin may be associated with improved outcomes compared with triple therapy.”
Disclosure: Brilakis reports receiving research support from Guerbet, consulting/speaker honoraria from BridgePoint Medical/Boston Scientific, Janssen, Sanofi-Aventis, St. Jude Medical and Terumo; providing expert testimony for Thompson Coe; and his spouse is an employee of Medtronic.
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