ESC Focus on Interventions & PC - 18

Selected Content

these individuals.
The recently published ESC guidelines on the diagnosis and treatment of PAD also indicate that clinicians
should perform complete vascular evaluation in all
patients being considered for heart transplantation or
cardiac assist device implantation (I C) [Aboyans V, Ricco
JB et al. Eur Heart J. 2017]. The guidelines also recommend that clinicians should consider screening for HF
with a transthoracic echocardiogram and/or natriuretic
peptides assessment in patients with symptomatic PAD
(IIa C). Clinicians should also consider screening for PAD
in patients with HF (IIb C), and should test for renal artery
disease in patients with flash pulmonary oedema (IIb C).

Updated Guidelines Focus on
Dual Antiplatelet Therapy in
Coronary Artery Disease
Written by Brian Hoyle

The European Society of Cardiology (ESC) guideline
update on dual antiplatelet therapy (DAPT) in patients
with coronary artery disease (CAD) reflects the burgeoning use of aspirin in combination with P2Y12 antagonists.
Advances have been made with drugs (prasugrel, ticagrelor) that have more predictable antiplatelet effect and the
completion of studies that have focused on the optimal
duration of DAPT. New drug-eluting stents have lowered
concerns of stent thrombosis allowing shorter DAPT duration and recent trials have demonstrated that patients
treated with prolonged DAPT have lower long-term risk of
ischaemic events. This focused update , presented at the
ESC Guidelines 2017 - Focused Update on Dual Antiplatelet
Therapy session on 27 August, was designed to provide
clinicians with guidance on the use of dual anti-platelet
therapy.
Risk Stratification Tools
This update introduced the DAPT and the PRECISE
DAPT scoring systems [Costa F et al. Lancet. 2017; Yeh
RW et al. JAMA. 2016] to provide an assessment of the
risk of ischaemic and bleeding events to help clinicians
guide clinical decision making (IIa A). These scores allow
providers to quantify both the risk of ischaemic and
bleeding events (Figure 1).
P2Y12 Choice, Time of Initiation, and Duration
Acute Coronary Syndrome (ACS)
The TRITON-TIMI 38 [Wiviott SD et al. N Engl J Med. 2007]
and PLATO trials [Wallentin L et al. N Engl J Med. 2009],
demonstrated the superiority of prasugrel and ticagrelor
over clopidogrel in the treatment of patients with ACS.
The focused update recommends the use of ticagrelor or
prasugrel over clopidogrel in patients with ACS (Table 1).

October 2017

Table 1. Recommendations for DAPT in ACS
Recommendations
In patients with ACS, ticagrelor (180 mg loading dose, 90 mg
twice daily) on top of aspirin is recommended, regardless of
initial treatment strategy, including patients pretreated with
clopidogrel (which should be discontinued when ticagrelor is
commenced) unless there are contraindications.
In patients with ACS undergoing PCl, prasugrel (60 mg
loading dose. 10 mg daily dose) on top of aspirin is recommended for P2Y12 inhibitor-naïve patients with NSTE-ACS
or initially conservatively managed STEMI if indication for
PCI is established, or in STEMI patients undergoing immediate coronary catheterisation unless there is a high risk
of life-threatening bleeding or other contraindications.

Class

Level

ACS, acute coronary syndrome; NSTE, non-ST elevation; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.

The guidelines also address the issue of pretreatment
with P2Y12 inhibitors. In the ACCOAST trial, pretreatment
with prasugrel did not reduce cardiovascular (CV) events
and increased the 30-day risk of TIMI major bleeding in
patients with non-STEMI [Montalescot G et al. N Engl J Med.
2013]. The ATLANTIC trial randomised patients with STEMI
to either pre-hospital or in-hospital loading with ticagrelor.
Pretreatment with ticagrelor did not increase the resolution of ST-segment elevation before PCI when compared
with in-hospital loading. However, the rates of definite
stent thrombosis were lower in the patients randomised to
pre-hospital ticagrelor (P = .02 at 30 days). Rates of major
bleeding events were similar in the 2 groups [Montalescot
G et al. N Engl J Med. 2014]. The updated guidelines have
several new recommendations concerning P2Y12 choice
and pretreatment including a recommendation for the
pretreatment of patients with STEMI who are undergoing PCI and pretreatment with ticagrelor in those patients
with NSTEMI undergoing invasive management (Table 2).
Table 2. Pretreatment Recommendations Concerning DAPT Type and
Duration in ACS Patients
Recommendations

Class

Level

Pretreatment with a P2Y12 inhibitor is generally recommended in patients in whom coronary anatomy is known
and the decision to proceed to PCI is made as well as in
patients with STEMI.

A
NEW

In patients with NSTE-ACS undergoing invasive management, ticagrelor administration (180 mg loading dose, 90 mg
BID), or clopidogrel (600 mg loading dose, 75 mg daily
dose) if ticagrelor is not an option, should be considered
as soon as the diagnosis is established.

IIa

In NSTE-ACS patients in whom coronary anatomy is not
known, it is not recommended to administer prasugrel.

III

NEW

NSTE-ACS, non-ST elevation acute coronary syndrome; PCI, percutaneous
coronary intervention; STEMI, ST-elevation myocardial infarction.

The DAPT trial randomised patients who were, still on
DAPT 12 months after placement of a DES, and had not
suffered an ischaemic or bleeding event, to either continued thienopyridine therapy or placebo. Aspirin was
maintained throughout the study period in both groups.

www.escardio.org/ESCcongressinreview

http://www.escardio.org/ESCcongressinreview

Table of Contents for the Digital Edition of ESC Focus on Interventions & PC