ESC Congress 2017 In Review -- Main Edition - 7

ESC Congress 2017

risk of ipsilateral stroke, provided documented perioperative stroke/death rates are < 3% and life expectancy
exceeds 5 years (Figure 3). Revascularisation in patients
with symptomatic 50% to 99% carotid stenosis should
be performed within 14 days of symptom onset.
Dual Antiplatelet Therapy in CAD
The 2017 ESC Focused Update on Dual Antiplatelet
Therapy in Coronary Artery Disease was developed
in collaboration with the European Association for
Cardio-Thoracic Surgery (EACTS). ESC DAPT Task
Force Chairperson, Marco Valgimigli, MD, Inselspital
Universitätsspital Bern, Bern, Switzerland, overviewed
the updated DAPT guideline. The recommendations
highlight the need for personalised use of DAPT in terms
of type and duration to maximise ischaemic protection
and minimise bleeding risk in patients with CAD.
All of the prior recommendations on DAPT have
been revised in the updated guideline (Figure 4).
According to the recommendations, clinicians may
consider the use of risk scores designed to evaluate
the benefits and risks of different DAPT durations. The
DAPT and PRECISE-DAPT scores have been validated
for making decisions about the duration of DAPT.
DAPT is not indicated for patients with stable CAD
and no history of prior MI who are undergoing medical

In Review

therapy only. After PCI with stent placement, DAPT is
considered standard of care. DAPT may be considered
for a limited duration in patients with stable CAD treated with PCI who are at high bleeding risk (Table 3).
In patients with acute coronary syndrome (ACS)
undergoing PCI or coronary artery bypass graft (CABG),
DAPT is indicated for 12 months in patients without high
bleeding risk (aspirin plus prasugrel, ticagrelor, or clopidogrel) and for 6 months in patients at high bleeding risk
(aspirin plus clopidogrel or ticagrelor). There is no indication for DAPT in patients with stable CAD undergoing
CABG unless there is a concomitant or prior indication.
Table 3. DAPT in High Bleeding-Risk Patients With Stable CAD Treated
With PCI
Recommendations
In patients with stable CAD considered at high bleeding
risk (eg, PRECISE-DAPT ≥25), DAPT for 3 months should
be considered.
In patients with stable CAD in whom 3-month DAPT poses
safety concerns, DAPT for 1 month may be considered.

Class

Level

IIa

IIb

CAD, coronary artery disease; DAPT, dual antiplatelet therapy; PCI, percutaneous coronary intervention.
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.

Figure 4. Changes in the 2017 Focused Update on DAPT

Change in Recommendations

New Recommendations 2017

Pretreatment with P2Y12 inhibitors
when PCI is planned

The occurence of actionable bleeding
while on DAPT should prompt reconsideration of type and duration of DAPT regimen

Before

2017

Liberal use of PPI to mitigate GI bleeding
risk
Elective surgery requiring discontinuation of the P2Y12 inhibitor after 1 month

The decision for DAPT duration should be
dynamic and reassessed during the course
of the initially selected DAPT regimen

Ticagrelor interruption of 3 days prior
elective surgery

Discontinuation of P2Y12 inhibitor
therapy after 6 months when stenting
ACS patients with PRECISE-DAPT ≥ 25

Dual therapy as an alternative to triple
therapy when bleeding risk outweighs
the ischaemic risk

6-month DAPT regimen in patients with
SCAD treated with drug-coated balloon

Discontinuation of antiplatelet treatment
in patients treated with OAC should be
considered at 12 months
Routine platelet function testing to
adjust therapy
I

IIa

IIb

Early administration of ticagrelor/clopidogrel in NSTE-ACS with invasive approach
Ticagrelor 60 mg BID preferred over
other oral P2Y12 inhibitors for DAPT
continuation ≥ 12 months in post MI

New / Revised Concepts
Metallic stent and DAPT duration
Switch between P2Y12 inhibitors
Risk scores to guide DAPT duration
- PRECISE DAPT score
- DAPT score
Speciﬁc proﬁling
- Definition of complex PCl
- Unfavourable profile for OAC and APT
- Gender considerations and special
populations
DAPT duration without stenting
- Medical management
- CABG or cardiac surgery
Anticoagulation and DAPT
- Acute and chronic setting
- Dosing regimen

III

ACS, acute coronary syndrome; APT, antiplatelet therapy; CABG, coronary artery bypass graft; DAPT, dual antiplatelet therapy; GI, gastrointestinal; MI, myocardial infarction;
NSTE, non-ST-segment elevation; OAC, oral anticoagulant; PCI, percutaneous coronary intervention; PPI, proton pump inhibitor; SCAD, stable coronary artery disease.
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.

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Congress 2017 In Review -- Main Edition