Dual antiplatelet therapy following percutaneous coronary intervention and stenting for chronic coronary syndrome in adults according to patient bleeding and ischemic risk category

Patient bleeding risk*	Patient ischemic risk^¶
Patient bleeding risk*	Average ischemic risk	High ischemic risk
Average bleeding risk	6 to 12 months of DAPT with aspirin 75 to 100 mg once daily plus clopidogrel 75 mg once daily, followed by aspirin monotherapy (75 to 100 mg once daily).^Δ	≥12 months of DAPT with aspirin 75 to 100 mg once daily plus clopidogrel 75 mg once daily, followed by aspirin monotherapy (75 to 100 mg once daily) (preferred).^Δ or 3 months of DAPT with aspirin 75 to 100 mg once daily plus ticagrelor 90 mg twice daily, followed by ≥12 months ticagrelor monotherapy (90 mg twice daily).^◊^§
High bleeding risk	1 month of DAPT with aspirin 75 to 100 mg once daily plus clopidogrel 75 mg once daily followed by clopidogrel monotherapy (75 mg once daily) for up to 12 months. After 12 months, either continue clopidogrel monotherapy or switch to aspirin (75 to 100 mg once daily).^¥ or 1 to 3 months of DAPT with aspirin 75 to 100 mg once daily plus ticagrelor 90 mg twice daily, followed by up to 12 months of ticagrelor 90 mg twice daily, followed by aspirin monotherapy (75 to 100 mg once daily).^§ or 1 to 6 months of DAPT with aspirin 75 to 100 mg once daily plus clopidogrel 75 mg once daily (with this choice, we treat with DAPT at the shorter end of the range, as the bleeding risk increases) followed by aspirin monotherapy (75 to 100 mg once daily) or clopidogrel 75 mg daily.	3 months of DAPT with aspirin 75 to 100 mg once daily plus ticagrelor 90 mg twice daily, followed by ≥12 months ticagrelor monotherapy (90 mg twice daily).^§ or 6 to 12 months of DAPT with aspirin 75 to 100 mg once daily plus clopidogrel 75 mg once daily, followed by monotherapy with either clopidogrel 75 mg once daily or aspirin 75 to 100 mg once daily.^Δ

Higher time range is favored if there is a higher ischemic risk and lower bleeding risk. Each practitioner and their patients must weigh the decrease in the risk of ischemic events with the increase in the rate of major bleeding. We carefully individualize the decision to continue DAPT for more than one year, taking into account predictors of bleeding or ischemic events. Refer to related UpToDate content for further information.

PCI: percutaneous coronary intervention; DAPT: dual antiplatelet therapy.

* Several bleeding risk factors are considered. Refer to related UpToDate content for further information.

¶ Ischemic risk is determined based on clinical judgement using PCI-related, stent-related, and/or clinical risk factors. This can also be integrated with the DAPT score, using <2 as average ischemic risk and ≥2 as high ischemic risk. Refer to related UpToDate content for further information.

Δ To guide the decision about whether to continue aspirin plus clopidogrel after 6 to 12 months, we use clinical and procedural risk factors and the DAPT risk calculator (DAPT score). For patients with a score of <2, we generally stop DAPT by 6 to 12 months. For patients without a major bleeding event and with a score of ≥2 (patients at higher ischemic risk), we generally continue DAPT therapy for an additional 18 months based on the DAPT study. Refer to related UpToDate content for further information.

◊ Aspirin plus ticagrelor for 3 months followed by ticagrelor monotherapy is a reasonable alternative in a minority of patients such as those with known clopidogrel hyporesponsiveness and those previously taking ticagrelor.

§ Some experts continue ticagrelor monotherapy for up to 2 years based on the GLOBAL LEADERS trial. When ticagrelor monotherapy is complete, switch to aspirin monotherapy (81 mg once daily).

¥ This recommendation is based on the STOPDAPT-2 trial.

References:

DAPT Risk Calculator. American College of Cardiology. Available at: https://tools.acc.org/DAPTriskapp/#!/content/calculator/ (Accessed on March 4, 2022).
Mauri L, Kereiakes DJ, Yeh RW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014; 371:2155.
Vranckx P, Valgimigli M, Jüni P, et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomized superiority trial. Lancet 2018; 392:940.
Capodanno D, Baber U, Bhatt DL, et al. P2Y12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol 2022; s41569-022.
Watanabe H, Domei T, Morimoto T, et al. Effect of 1-month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: The STOPDAPT-2 Randomized Clinical Trial. JAMA 2019; 321:2414.

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خرید پکیج

Dual antiplatelet therapy following percutaneous coronary intervention and stenting for chronic coronary syndrome in adults according to patient bleeding and ischemic risk category