ESC Focus on Interventions & PC - 19

ESC Congress 2017

In Review

Interventions &
Peripheral Circulation
Patients randomised to long-term DAPT had lower
rates of stent thrombosis (0.4% vs 1.4%; P < .001) and
CV events (4.3% vs 5.9%; P < .001). The reduction in
ischaemic events was counterbalanced by an increase
in GUSTO moderate/severe bleeding (2.5% vs 1.6%;
P < .001) and an increase in total mortality. Similarly, in
the PEGASUS-TIMI 54 trial [Bonaca MP et al. N Engl J
Med. 2015] patients 1-3 years following an MI had lower
rates CV death, MI, or stroke when randomised to longterm therapy with aspirin and ticagrelor compared with
aspirin alone. TIMI major bleeding was increased with
prolonged DAPT, but there were no differences in fatal
bleeding or intracranial haemorrhage (P = .43 and P = .47
for 90 and 60 mg ticagrelor, respectively). A recent
meta-analysis of 6 randomised controlled trials involving over 33,000 patients with prior MI reported a reduction of ischaemic events with extended DAPT compared
with aspirin alone (6.4% vs 7.5%; P = .001) at the cost of
increased major bleeding (1.85% vs 1.09; P = .004), but
not fatal bleeding (0.14% vs 0.17%; P = .75). There was
no increase in non-CV death in patients with prolonged
DAPT (RR 1.03; 95% CI, 0.86-1.23; P = .76) [Udell JA et
al. Eur Heart J. 2016].
The new ESC guidelines recommend duration of
DAPT be tailored based upon the risk of bleeding and
ischaemic events. If bleeding is not a concern, DAPT
can be maintained for 1 year or longer. In particular, the
guidelines recommend ticagrelor 60 mg twice daily in
those patients who are > 12 months following ACS and
are being treated with prolonged DAPT. Prasugrel has
not been to shown to improve outcomes in patients with
ACS who are medically managed (Table 3).

Table 3. Recommendations for DAPT After PCI
Recommendations

Class

Level

In patients with ACS treated with coronary stent implantation, DAPT with a P2Y12 inhibitor on top of aspirin is recommended for 12 months unless there are contraindications
such as excessive risk of bleeding (eg, PRECISE-DAPT ≥ 25).

I

UPDATED

In patients with ACS and stent implantation who are at high
risk of bleeding (eg, PRECISE-DAPT ≥ 25), discontinuation of
P2Y12 inhibitor therapy after 6 months should be considered.

IIa

In patients with ACS who have tolerated DAPT without a
bleeding complication, continuation of DAPT for longer
than 12 months may be considered.

IIb

In patients with MI and high ischaemic risk who have tolerated DAPT without a bleeding complication, ticagrelor
60 mg BID for longer than 12 months on top of aspirin
may be preferred over clopidogrel or prasugrel.

IIb

A

B

NEW
A
NEW

B
UPDATED

ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy; MI, myocardial
infarction.

Stable CAD
Clopidogrel remains the P2Y12 inhibitor of choice in patients
with stable CAD. DAPT with ticagrelor or prasugrel in addition to aspirin may be considered instead of clopidogrel in
stable CAD patients undergoing PCI (IIb C). Pretreatment
with clopidogrel can be considered for patients with stable CAD if the probability of PCI is high (IIb C). The updated guidelines have identified features that increase the
risk of recurring ischaemic events due to the presence of
a stent (Table 4).
The updated guidelines reflect the movement away
from prevention of stent-related thrombosis to reducing ischaemic events. In patients with prior PCI, DAPT
with aspirin and clopidogrel is generally recommended
for 12 months, regardless of stent type (I A). Data from

Figure 1. Risk Scores Validated for DAPT Duration
PRECISE-DAPT Score

DAPT Score

Time of use

At the time of coronary stenting

After 12 months of unevenful DAPT

DAPT duration strategies
assessed

Short DAPT (3-6 months)
vs
Standard/long DAPT (12-14 months)

Short DAPT (12 months)
vs
Standard/long DAPT (30 months)

Score calculation

HB
WBC
Age
CrCI
Prior bleeding
Score points

≥12 11-5

11

10-5 ≤10

Age

≥5 8 10 12 14 16 18 ≥20
≤50

60

≥100

80

70
60

No

80
40

≥90
20

0
Yes

0 2 4 6 8 10 12 14 16 18 20 22 24 26 2830

≥ 75
65 to < 75
< 65
Cigarette smoking
Diabetes mellitus
MI at presentation
Prior PCI or prior MI
Paclitaxel-eluting stent
Stent diameter < 3 mm
CHF or LVEF < 30 %
Vein graft stent

-2 pt
-1 pt
0 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 2 pt
+ 2 pt

Score range

0 to 10 points

Decision making cut-off
suggested

Score ≥ 25 ➞ Short DAPT
Score < 25 ➞ Standard/long DAPT

Score ≥ 2 ➞ Long DAPT
Score < 2 ➞ Standard DAPT

Calculator

www.precisedaptscore.com

https://qxmd.com/calculate/calculator_373/dapt-score

-2 to 10 points

CHF, congestive heart failure; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; HB, haemoglobin; LVEF, left ventricular ejection fraction; MI, myocardial
infarction; PCI, percutaneous coronary intervention; WBC, white blood cell count.

Official Peer-Reviewed Highlights From ESC Congress 2017

19
https://qxmd.com/calculate/calculator_373/dapt-score http://www.precisedaptscore.com
Table of Contents for the Digital Edition of ESC Focus on Interventions & PC
