2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

Valgimigli, Marco; Bueno, Héctor; Byrne, Robert A.; Collet, Jean‐Philippe; Costa, Francesco; Jeppsson, Anders; Jüni, Peter; Kastrati, Adnan; Kolh, Philippe; Mauri, Laura; Montalescot, Gilles; Neumann, Franz‐Josef; Petričević, Mate; Roffi, Marco; Steg, Philippe Gabríel; Windecker, Stephan; Zamorano, José Luís; Levine, Glenn N.; Badimon, Lina; Vranckx, Pascal; Agewall, Stefan; Andreotti, Felicita; Antman, Elliott M.; Barbato, Emanuele; Bassand, Jean‐Pierre; Bugiardini, Raffaele; Çıkırıkçıoğlu, Mustafa; Cuisset, Thomas; Bonis, Michele De; Delgado, V.; Fitzsimons, Donna; Gaemperli, Oliver; Galiè, Nazzareno; Gilard, Martine; Hamm, Christian W.; Ibáñez, Borja; Iung, Bernard; James, Stefan; Knuuti, Juhani; Landmesser, Ulf; Leclercq, Christophe; Lettino, Maddalena; Lip, Gregory Y.H.; Piepoli, Massimo F; Piérard, Luc; Schwerzmann, Markus; Sechtem, Udo; Simpson, Iain; Sousa-Uva, Miguel; Stabile, Eugenio; Storey, Robert F.; Tendera, Michał; Werf, Frans Van de; Verheugt, Freek W.A.; Aboyans, Victor; Coca, António; Coman, Ioan Mircea; Dean, Veronica; Delgado, Victoria; Hindricks, Gerhard; Katus, Hugo A.; Lancellotti, Patrizio; McDonagh, Theresa A.; Ponikowski, Piotr; Richter, Dimitrios J; Shlyakhto, Evgeny; Roithinger, Franz Xaver; Aliyev, Farid; Стельмашок, В. И.; Desmet, Walter; Postadzhiyan, Arman; Georghiou, Georgios P.; Moťovská, Zuzana; Grove, Erik Lerkevang; Marandi, Toomas; Kiviniemi, Tuomas; Kedev, Saško; Maßberg, Steffen; Alexopoulos, Dimitrios; Kiss, Róbert Gábor; Guðmundsdóttir, Ingibjörg; McFadden, Eugène; Lev, Eli I.; Luca, Leonardo De; Sugraliyev, Akhmetzhan; Haliti, Edmond; Mirrakhimov, Aibek E.; Latkovskis, Gustavs; Petrauskienė, Birutė; Huijnen, Steve; Magri, Caroline Jane; Cherradi, R; Berg, Jürrien M. ten; Eritsland, Jan; Budaj, Andrzej; Aguiar, Carlos; Duplyakov, D. V.; Zavatta, Marco; Antonijević, Nebojša; Fras, Zlatko; Montoliu, Antonio Tello; Varenhorst, Christoph; Tsakiris, Dimitri; Addad, Faouzi; Aydoğdu, Sinan; Parkhomenko, Alexander; Kinnaird, Tim

doi:10.1093/eurheartj/ehx419

Cited by 2,215 publications

(541 citation statements)

References 261 publications

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“…This could potentially make older patients more prone to side effects and less to predictable effectiveness 14. In current clinical practice, all patients with ACS undergoing PCI are recommended to receive standard therapy of antiplatelet agents, irrespective of age 15. However, patients who are 75 years or older are often underrepresented or even excluded in randomized trials.…”

Section: Discussionmentioning

confidence: 99%

In‐Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75 Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome) Project

Zhao

Zhou

et al. 2018

JAHA

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BackgroundElderly patients with acute coronary syndrome (ACS) are at high risk for ischemic and bleeding events. This study aimed to evaluate the clinical effectiveness and safety of dual loading antiplatelet therapy for patients 75 years and older undergoing percutaneous coronary intervention for ACS.Methods and ResultsThe Improving Care for Cardiovascular Disease in China‐ACS project was a collaborative study of the American Heart Association and Chinese Society of Cardiology. A total of 5887 patients 75 years and older with ACS who had percutaneous coronary intervention and received dual antiplatelet therapy with aspirin and P2Y12 inhibitors (clopidogrel or ticagrelor) between November 2014 and June 2017 were enrolled. The primary effectiveness and safety outcomes were in‐hospital major adverse cardiovascular events and major bleeding. Hazard ratios (HRs) of in‐hospital outcomes with different loading statuses of antiplatelet therapy were estimated using Cox proportional hazard models with multivariate adjustment. A propensity score–matched analysis was also conducted. Compared with patients receiving a dual nonloading dose, patients taking a dual loading dose had increased risks of both major adverse cardiovascular events (HR, 1.66, 95% confidence interval, 1.13–2.44; [P=0.010]) and major bleeding (HR, 2.34, 95% confidence interval, 1.75–3.13; [P<0.001]). Among 3284 propensity score–matched patients, a dual loading dose was associated with a 1.36‐fold risk of major adverse cardiovascular events (HR, 1.36; 95% confidence interval, 0.88–2.11 [P=0.168]) and a 2.08‐fold risk of major bleeding (HR, 2.08; 95% confidence interval, 1.47–2.93 [P<0.001]).ConclusionsA dual loading dose of antiplatelet therapy was associated with increased major bleeding risk but not with decreased major adverse cardiovascular events risk among patients 75 years and older undergoing percutaneous coronary intervention for ACS in China.Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02306616.

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Section: Discussionmentioning

confidence: 99%

In‐Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75 Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome) Project

Zhao

Zhou

et al. 2018

JAHA

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“…While limited by the observational nature of the study and relatively small number of events, our findings lend support to these Class IIb recommendations (which were based on limited data) by showing no excess ischemic risk in patients who discontinued prasugrel or changed to a less‐potent agent based on justified medical decision (presumably related, at least in part, to higher bleeding risk). Along the same lines, a focused guideline update by the European Society of Cardiology recommended that in patients with ACS at high risk of bleeding, discontinuation of P2Y12‐inhibitor therapy after 6 months post‐stenting should be considered, as the risk of ischemic complication is highest immediately after the index event and then gradually declines 23. These recommendations were based on studies including primarily non‐ST segment elevation–ACS patients treated with clopidogrel,24 and the need for further studies focusing on novel P2Y12 inhibitors was explicitly acknowledged 23.…”

Section: Discussionmentioning

confidence: 99%

“…Along the same lines, a focused guideline update by the European Society of Cardiology recommended that in patients with ACS at high risk of bleeding, discontinuation of P2Y12‐inhibitor therapy after 6 months post‐stenting should be considered, as the risk of ischemic complication is highest immediately after the index event and then gradually declines 23. These recommendations were based on studies including primarily non‐ST segment elevation–ACS patients treated with clopidogrel,24 and the need for further studies focusing on novel P2Y12 inhibitors was explicitly acknowledged 23. Properly designed prospective studies are needed to assess tailored approaches for defining the potency and duration of antiplatelet therapy following STEMI, accounting for individual‐patient bleeding and ischemic risk.…”

Section: Discussionmentioning

confidence: 99%

Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST‐Elevation Myocardial Infarction

Koskinas

Zanchin

Klingenberg

et al. 2018

JAHA

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BackgroundEarly withdrawal of recommended antiplatelet treatment with clopidogrel adversely affects prognosis following percutaneous coronary interventions. Optimal antiplatelet treatment is essential following ST‐segment elevation myocardial infarction (STEMI) given the increased risk of thrombotic complications. This study assessed the frequency, predictors, and clinical impact of early prasugrel cessation in patients with STEMI undergoing primary percutaneous coronary interventions.Methods and ResultsWe pooled patients with STEMI discharged on prasugrel in 2 prospective registries (Bern PCI Registry [NCT02241291] and SPUM‐ACS (Inflammation and Acute Coronary Syndromes) [NCT01000701]) and 1 STEMI trial (COMFORTABLE‐AMI (Comparison of Biomatrix Versus Gazelle in ST‐Elevation Myocardial Infarction) [NCT00962416]). Prasugrel treatment status at 1 year was categorized as no cessation; crossover to another P2Y12‐inhibitor; physician‐recommended discontinuation; and disruption because of bleeding, side effects, or patient noncompliance. In time‐dependent analyses, we assessed the impact of prasugrel cessation on the primary end point, a composite of cardiac death, myocardial infarction, and stroke. Of all 1830 included patients (17% women, mean age 59 years), 83% were treated with new‐generation drug‐eluting stents. At 1 year, any prasugrel cessation had occurred in 13.8% of patients including crossover (7.2%), discontinuation (3.7%), and disruption (2.9%). Independent predictors of any prasugrel cessation included female sex, age, and history of cerebrovascular event. The primary end point occurred in 5.2% of patients and was more frequent following disruption (hazard ratio 3.04, 95% confidence interval,1.34–6.91; P=0.008), without significant impact of crossover or discontinuation. Consistent findings were observed for all‐cause death, myocardial infarction, and stent thrombosis following prasugrel disruption.ConclusionsIn this contemporary study of patients with STEMI, early prasugrel cessation was not uncommon and primarily involved change to another P2Y12‐inhibitor. Disruption was the only type of early prasugrel cessation associated with statistically significant excess in ischemic risk within 1 year following primary percutaneous coronary interventions.

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“…• Adapted from ESC guideline statement 3 There is also an emerging interest in evaluation of the efficacy of combination therapy with OAC and single antiplatelet agent in improving clinical outcome. In the recently published COMPASS 89 trial, in patients with stable CAD, addition of rivaroxaban to aspirin lowered major vascular events (4% vs. 6%; HR: 0.74, 95% CI 0.65-0.86, p<0.0001), but increased major bleeding (3% vs.2%; HR 1.66, p<0.0001).…”

Section: Table 9 Recommended Therapeutic Strategies For Patients Needmentioning

confidence: 99%

“…As we celebrate the various advances in the techniques and technology of transcatheter therapeutics in this 40 th year of Interventional Cardiology, optimal duration of DAPT continue to be elusive. Most recent transatlantic guidelines have called for the comprehensive assessment of ischemic and bleeding risks thus emphasizing individualization of DAPT 2,3 . The following review is aimed at critically evaluating the available evidence to help make crucial clinical decisions regarding duration of DAPT and triple therapy.…”

Section: Introductionmentioning

confidence: 99%

Dual Antiplatelet Therapy (DAPT) in Coronary Artery Disease: A Daunting Dilemma

Chaturvedula¹,

Diver²,

Vashist³

2018

Preprint

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Percutaneous coronary intervention(PCI) with stenting for the treatment of acute coronary syndrome(ACS) is the contemporary standard of care. Such treatment is followed by Dual anti-platelet therapy(DAPT) comprising of aspirin and a P2Y12 inhibitor. The efficacy of this therapy has been well established but the optimal duration of DAPT remains elusive, and has thus far attracted a prodigious deal of scientific attention. Decision regarding DAPT duration can be challenging clinically in the modern era with the evolution of newer stents, more potent antiplatelet agents and novel anticoagulant drugs in addition to an older patient population with multiple comorbidities. Major societal guidelines have emphasized comprehensive assessment of ischemic and bleeding risk, in turn recommending individualization of DAPT duration, thus encouraging "shared decision making". The following review is aimed at critically evaluating the available evidence to help make these crucial clinical decisions regarding duration of DAPT and triple therapy.

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2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

Cited by 2,215 publications

References 261 publications

In‐Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75 Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome) Project

In‐Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75 Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome) Project

Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST‐Elevation Myocardial Infarction

Dual Antiplatelet Therapy (DAPT) in Coronary Artery Disease: A Daunting Dilemma

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