Journal of the American College of Cardiology
ACC/AHA Focused Update
2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery DiseaseA Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
Glenn N. Levine, Eric R. Bates, John A. Bittl, Ralph G. Brindis, Stephan D. Fihn, Lee A. Fleisher, Christopher B. Granger, Richard A. Lange, Michael J. Mack, Laura Mauri, Roxana Mehran, Debabrata Mukherjee, L. Kristin Newby, Patrick T. O’Gara, Marc S. Sabatine, Peter K. Smith and Sidney C. Smith Jr.
Table 3
Table 3
Overriding Concepts and Updated Recommendations for DAPT and Duration
| Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, as well as prolongation of DAPT, necessitates a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions about treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and consideration of patient preference. |
| In general, shorter-duration DAPT can be considered for patients at lower ischemic risk with high bleeding risk, whereas longer-duration DAPT may be reasonable for patients at higher ischemic risk with lower bleeding risk. |
| Prior recommendations for duration of DAPT for patients treated with DES were based on data from “first-generation” DES, which are rarely if ever used in current clinical practice. Compared with first-generation stents, newer-generation stents have an improved safety profile and lower risk of stent thrombosis. Recommendations in this focused update apply to newer-generation stents. |
| Updated recommendations for duration of DAPT are now similar for patients with NSTE-ACS and STEMI, as both are part of the spectrum of acute coronary syndrome. |
| A Class I recommendation (“should be given”) in most clinical settings is made for at least 6–12 months of DAPT (depending on the setting), and a Class IIb recommendation (“may be reasonable”) is made for prolonged DAPT beyond this initial 6- to 12-month period. |
| In studies of prolonged DAPT after DES implantation or after MI, duration of therapy was limited to several years (akin to many other studied therapies). Thus, in patients for whom the benefit/risk ratio seemingly favors prolonged therapy, the true optimal duration of therapy is unknown. |
| Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD. |
| Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection (56–60) than are higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range, 75 mg to 100 mg). |
CAD indicates coronary artery disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; MI, myocardial infarction; NSTE-ACS, non–ST-elevation acute coronary syndrome; and STEMI, ST-elevation myocardial infarction.
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