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Table 4. High-Risk Features of Stent-Driven Recurrent Ischaemic
Events
Prior stent thrombosis on adequate antiplatelet therapy.
Stenting of the last remaining patent coronary artery.
Diffuse multivessel disease especially in diabetic patients.
Chronic kidney disease (ie, creatinine clearance < 60 mL/min).
At least three stents implanted.
At least three lesions treated.
Bifurcation with two stents implanted.
Total stent length > 60 mm.
Treatment of a chronic total occlusion.

small trials (RESET [Kim BK et al. J Am Coll Cardiol. 2012];
OPTIMIZE [Feres F et al. JAMA . 2013]) support a shorter
DAPT period of 3 months in stable CAD patients at high risk
of bleeding (IIa B). If the 3-month regimen has safety concerns for patients receiving drug-eluting stents, the findings of the ZEUS [Valgigli M et al. Am Heart J. 2013] and
LEADERS FREE [Urban P et al. N Engl J Med. 2015] trials
indicate that a 1-month DAPT could be considered (IIb C).
Switching of Therapy
In patients with ACS who were previously exposed to
clopidogrel, switching from clopidogrel to ticagrelor is
recommended early after hospital admission at a loading dose of 180 mg irrespective of timing and loading
dose of clopidogrel unless contraindications to ticagrelor exist (I B). Contraindications to ticagrelor include
prior intracranial haemorrhage or continuing bleeding
events. Further switching between oral P2Y12 inhibitors
may be considered in cases of drug intolerance or drugrelated side effects (IIb C).
Oral Anticoagulation (OAC) Patients
Of all the DAPT studies done over the past 2 decades, only
3 have addressed the duration of DAPT in patients receiving OAC therapy. Decisions concerning DAPT for OAC
patients need to be done on a case-by-case basis, considering the higher risk of clinically significant bleeding during DAPT and with the knowledge that these patients have
an unfavourable patient profile compared with those not
requiring OAC therapy, including shorter life expectancy,
poor expected adherence to treatment, advanced age, endstage renal failure, history of major bleeding/haemorrhagic
stroke, and anaemia [Valgimigli M et al. Eur Heart J. 2017].
The decision to treat needs to first consider the nature
of the concern-ischaemic risk or bleeding risk. The prevailing concern will dictate whether triple therapy with aspirin, clopidogrel, and OAC is continued after the first month
for up to 6 months and followed by dual aspirin/OAC or
clopidogrel/OAC therapy (ischaemic risk), or whether the

October 2017

triple therapy is replaced at 1 month by the dual therapy
that is continued for up to 12 months (bleeding risk).
In the PIONEER AF-PCI trial [Gibson CM. N Engl J Med.
2016], clinically significant bleeding was less frequent for
participants with atrial fibrillation (AF) undergoing PCI with
placement of stents treated with low-dose rivaroxaban plus
a P2Y12 inhibitor for 12 months or very-low-dose rivaroxaban plus DAPT for 1, 6, or 12 months, compared with standard therapy with a vitamin K antagonist plus DAPT.
Patients Undergoing Surgery
The final portion of the updated guidelines considers
the type, duration, and management of DAPT in patients
undergoing surgery. For cardiac surgery patients, decisions need to consider the patient's status, coronary
anatomy, and when it is safe to resume DAPT for the surgery. Reflecting this complexity, the updated guidelines
have 8 recommendations based on patient status.
Patients requiring nonemergent cardiac surgery can
continue aspirin at a low daily dose, given the metaanalysis evidence of aspirin's benefit in lessening subsequent MI [Hastings S et al. Brit J Anaesth. 2015].
For patients receiving P2Y12 inhibitors who require nonemergent surgery, the procedure should be delayed for
at least 3, 5, and 7 days after stopping ticagrelor, clopidogrel, and prasugrel, respectively (IIa B).
No studies have addressed the resumption of DAPT
after cardiac surgery. Evidence gleaned from a meta-analyses, subgroup analyses of larger ACS trials, and observational studies suggests that DAPT can be resumed as soon
as it is judged safe to do so. The optimal timing to resume
DAPT is unclear, but 24-96 hours after CABG is reasonable,
with a shorter time for following stent implantation and a
longer time if AF is a concern. Once treatment is resumed,
the length of treatment is standard.
The recommendations for noncardiac surgery
patients are fairly similar with 2 exceptions. DAPT
should not be discontinued within the first month of
treatment (III B). Secondly, following implantation of a
coronary stent, elective surgery that necessitates the
discontinuation of P2Y12 inhibitor should not be done
until after 1 month (IIa B).
DAPT is not utilised only to reduce the risk of stent
thrombosis, but rather to reduce all CV events in patients
with CAD. Decisions regarding the use of DAPT (indication, time of initiation, therapy choice, interruptions,
duration) are complex and multiple factors need to be
taken into account, including clinical setting, treatment
modality for ACS/CAD, devices, bleeding risk, and concomitant therapies.
All figures and tables in this article are reprinted from Valgimigli M et al. 2017
ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J. 2017. doi:10.1093/eurheartj/
ehx419. By permission of Oxford University Press on behalf of the European
Society of Cardiology.

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