Review

Dual antiplatelet therapy after percutaneous coronary intervention: Personalize the duration

Travis M. Howard, MD and Umesh N. Khot, MD
Cleveland Clinic Journal of Medicine June 2021, 88 (6) 325-332; DOI: https://doi.org/10.3949/ccjm.88a.20113

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Recommended duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stents. Class of recommendation and level of evidence: class I, benefit much greater than risk; class II, benefit greater than risk, with conflicting evidence or opinion; class IIa, weight of evidence or opinion is in favor of usefulness; class IIb, usefulness is less well established. Level of evidence: A, from multiple randomized clinical trials; B or BR, from one or more randomized trials; C or C-LD, from nonrandomized observational studies.

    ACC = American College of Cardiology; ACS = acute coronary syndrome; AHA = American Heart Association; DAPT = dual antiplatelet therapy; DES = drug-eluting stent; ESC = European Society of Cardiology; PCI = percutaneous coronary intervention; SIHD = stable ischemic heart disease

    Information from references 6 and 7.

  • Figure 2
    Figure 2

    Guidelines for preoperative management of patients with coronary stents undergoing noncardiac surgery.

  • Figure 3
    Figure 3

    Guidelines for bridging before surgery in patients with prior coronary stent.

Tables

  • TABLE 1

    Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention with a drug-eluting stent

    Initial DAPT duration
    The rigid 1-year recommendation for initial DAPT duration has been revised, and the optimal duration is now defined by balancing risk of bleeding vs avoiding future ischemic events
    In patients with high bleeding risk or low ischemic risk, or both, shorter durations of DAPT are favored; in those with low bleeding risk or high ischemic risk, or both, longer durations of DAPT are favored
    Perioperative management of DAPT for noncardiac surgery
    Consider: Risk of bleeding during surgery while on DAPT
        Risk of stent thrombosis
        Consequences of delaying surgery
    Avoid surgery while patient is on DAPT unless emergent or bleeding risk is minimal
    Risk of stent thrombosis is highest initially and decreases over time but is never zero. If possible, delay surgery for at least 3 months and ideally for 6 months
    If DAPT is interrupted, continue aspirin, as it protect against stent thrombosis
    Consider bridging with intravenous antiplatelet agents if the risk of stent thrombosis is particularly high and surgery cannot be delayed
    Long-term DAPT (> 12 months)
    Appraise the risks and benefits for the individual patient
    Consider in patients at high risk of future ischemic events (eg, patients who have had prior myocardial infarction) and low bleeding risk
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