![Duration of DAPT in Patients With ACS Treated With
Medical Therapy Alone
• NO revascularization or fibrinolytic therapy – DAPT [Low dose
aspirin and P2Y12 inhibitor therapy (clopidogrel or ticagrelor)]
should be continued for at least 12 months(COR-1).
• In patients with NSTE–ACS who are managed with medical
therapy alone and treated with DAPT, it is reasonable to use
ticagrelor in preference to clopidogrel for maintenance P2Y12
inhibitor therapy.(COR-2A)](https://image.slidesharecdn.com/guidelinesforthemanagementofpatientswithunstable-240525120935-3555d860/85/Antiplatelets-in-IHD-Dose-Duration-DAPT-vs-SAPT-15-320.jpg)
Antiplatelets in IHD, Dose Duration, DAPT vs SAPT
- 2. Points to be covered • Current antiplatelet drugs • DAPT • Antiplatelets in 1. stable angina with no intervention. 2. stable angina with intervention. 3. unstable angina. 4. ACS Treated With Medical Therapy Alone. 5. ST-elevation (STE)-ACS and receiving fibrinolytic therapy. 6. ACS and Primary PCI 7. CABG
- 3. Current oral antiplatelets used in IHD
- 4. DAPT Aspirin (low dose) + P2Y12 inhibitor • PLATO Trial - A significant reduction in mortality occurred with ticagrelor compared to clopidogrel. • TRITON study - Demonstrated no net benefit of prasugrel compared with clopidogrel for patients with low body weight (<60 kg) or those ≥75 years of age . Found net harm with prasugrel for patients with previous transient ischemic attack or cerebrovascular accident. • POPular AGE study - In patients aged 70 years or older presenting with NSTE- ACS, clopidogrel is a favourable alternative to ticagrelor, because fewer bleeding events were found without an increase in the combined endpoint of all-cause death, myocardial infarction, stroke, and bleeding.
- 5. 1) Stable Angina no intervention • In patients with stable angina low-dose aspirin is recommended to reduce atherosclerotic events. • Dose - 81 mg (75-100 mg) • Routine combination of aspirin and a P2Y12 inhibitor is not recommended due to an excessive risk of bleeding. • European Society of Cardiology recommend daily use of low-dose aspirin, and if allergic to aspirin then Clopidogrel can be used.
- 6. Aspirin monotherapy or Clopidogrel monotherapy? • In Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial interpreted that there was a relative increase (3.7%) in risk of Myocardial infarction with clopidogrel only group. • Clopidogrel reduced the rate of ischemic rehospitalizations compared with aspirin when all 3 risk factors were taken into account - Ischaemic stroke, myocardial infarction, or vascular death
- 8. 2) Stable Angina with intervention In patients with SIHD revascularized with BMS - DAPT given for minimum of 1 month DES - DAPT should be given for at least 6 month. (DAPT – low dose aspirin (75-100) and P2Y12 Inhibitor
- 10. Unstable Angina • Aspirin (ASA) is the first choice and is administered as soon as possible after presentation and continued indefinitely. • clopidogrel should be administered to patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance. • A loading dose of non–enteric-coated aspirin 162 mg to 325 mg is the initial antiplatelet therapy. • Maintenance dose is 75 mg per day to 150 mg per day , lifelong.
- 11. CURE trial. • Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events (CURE) trial. • Among 12562 patients, the combination of clopidogrel and aspirin lowered the composite of death, MI, or stroke by 21% at 30 days compared with aspirin alone.
- 12. CURE Trial
- 13. In patients with ST-elevation (STE)-ACS and receiving fibrinolytic therapy • With an initial non-invasive strategy, add a loading dose followed by daily maintenance dose of clopidogrel or ticagrelor to aspirin (DAPT) and anticoagulation as soon as possible after admission and up to 12 month • Ticagrelor has rapid onset of action compared with clopidogrel, while also allowing a higher level of platelet inhibition and more rapid reversal compared with clopidogrel. (PLATO STUDY)
- 15. Duration of DAPT in Patients With ACS Treated With Medical Therapy Alone • NO revascularization or fibrinolytic therapy – DAPT [Low dose aspirin and P2Y12 inhibitor therapy (clopidogrel or ticagrelor)] should be continued for at least 12 months(COR-1). • In patients with NSTE–ACS who are managed with medical therapy alone and treated with DAPT, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy.(COR-2A)
- 16. Duration of DAPT in Patients With STEMI Treated With Fibrinolytic Therapy • In patients with STEMI treated with fibrinolytic therapy, DAPT therapy should be continued for a minimum of 14 days and ideally at least 12 months.(COR-1) • And if they tolerate DAPT without bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT for longer than 12 months may be reasonable.(COR- 2B)
- 18. In Patients with ACS and Primary PCI • 2021 , Class I and IIa American College of Cardiology/American Heart Association Guideline Recommendations for Antiplatelet Therapy in Patients Receiving Primary PCI- • Aspirin 162 to 325 mg load before procedure f/b 75-100mg daily maintenance dose. • Clopidogrel load: 600 mg as early as possible or at time of PCI. f/b 75mg daily for 1 year. • Prasugrel load: 60 mg as early as possible or at time of PCI f/b 10mg daily for 1 year. • Ticagrelor load: 180 mg as early as possible or at time of PCI f/b 90mg teice a day for 1 year.
- 19. COR Recommendations I In patients withACS (NSTE-ACS or STEMI) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months. I In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended. IIa In patients withACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy. IIa In patients withACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation who are not at high risk for bleeding complications and who do not have a history of stroke or TIA, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy. Duration of DAPT in Patients With ACS Treated With PCI
- 20. Duration of DAPT in Patients With ACS Treated With PCI COR Recommendations IIb In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable . IIb In patients with ACS treated with DAPT after DES implantation who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy), are at high risk of severe bleeding complication (e.g., major intracranial surgery), or develop significant overt bleeding, discontinuation of P2Y12 inhibitor therapy after 6 months may be reasonable. III: Harm Prasugrel should not be administered to patients with a prior history of stroke or TIA.
- 22. Recommendations for Duration of DAPT in Patients Undergoing CABG COR Recommendations I In patients treated with DAPT after coronary stent implantation who subsequently undergo CABG, P2Y12 inhibitor therapy should be resumed postoperatively so that DAPT continues until the recommended duration of therapy is completed. I In patients withACS (NSTE-ACS or STEMI) being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy afterACS. I In patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended. IIb In patients with SIHD, DAPT (with clopidogrel initiated early postoperatively) for 12 months after CABG may be reasonable to improve vein graft patency.
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