Chest
Volume 141, Issue 2, Supplement, February 2012, Pages e637S-e668S
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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles
Primary and Secondary Prevention of Cardiovascular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.11-2306Get rights and content

Background

This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies.

Methods

The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

Results

We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B).

Conclusions

Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.

Section snippets

Summary of Recommendations

Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.

2.1. For persons aged 50 years or older without symptomatic cardiovascular disease, we suggest low-dose

Methods

Table 1 describes the clinical questions (ie, population, intervention, comparator, and outcome) for each of the recommendations that follow. We define only patient characteristics relevant to our questions. For example, because whether ACS occurs with or without ST-segment elevation is not relevant to long-term secondary prevention, we provide a single set of recommendations for all patients following ACS. We have selected the same patient-important outcomes across all recommendations (eg,

Primary Prevention of Cardiovascular Disease

In this section, we address the effects of aspirin in primary prevention of cardiovascular disease. In addition, we consider recent meta-analyses demonstrating a reduction in cancer mortality and total mortality with long-term use of aspirin.4, 5, 6 We do not include other antiplatelet therapies (eg, clopidogrel alone or in combination with aspirin) or oral anticoagulation (eg, warfarin) because they are not likely used in primary prevention. Whether aspirin should be prescribed in patients

Secondary Prevention of Cardiovascular Disease

The evidence supporting the use of specific antithrombotic therapies sometimes differs between patients who have recently experienced an ACS and those with stable CAD. For purposes of these guidelines, and based on available data, recommendations for therapy following ACS will apply to the postdischarge period and extend to 1 year. Thereafter, patients will be considered to have established CAD. This definition is by necessity somewhat arbitrary, and we acknowledge that the higher-risk period

Antithrombotic Therapy Following Elective PCI

Choice and duration of antiplatelet therapy following PCI depends on the setting (acute vs elective), whether a stent is placed, and the type of stent (DES vs BMS) placed. We have previously discussed evidence for antithrombotic therapy following PCI in patients with ACS. In this section, we discuss antithrombotic therapy following elective PCI. As in prior sections, we address the patient-important outcomes of death, nonfatal MI, nonfatal stroke (if reported), and major bleeding.

Antithrombotic Therapy in Patients With Systolic LV Dysfunction

Approximately 70% of patients with systolic LV dysfunction and heart failure have ischemic heart disease. The remaining 30% of patients with systolic heart failure are considered to have a nonischemic etiology (eg, hypertensive heart disease, valvular heart disease, idiopathic). Because the majority of these latter patients are free of concomitant CAD, risk for MI is lower than that of patients with ischemic systolic LV dysfunction.

Acknowledgments

Author contributions: As Topic Editor, Dr Vandvik oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.

Dr Vandvik: served as Topic Editor.

Dr Lincoff: served as a panelist.

Dr Gore: served as a panelist.

Dr Gutterman: served as a panelist.

Dr Sonnenberg: served as a resource consultant.

Dr Alonso-Coello: served as a panelist.

Dr Akl: served as a panelist.

Dr Lansberg: served as a panelist.

Dr Guyatt: served as a panelist.

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    Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.

    Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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