Dual antiplatelet therapy (DAPT; combination of a P2Y12 inhibitor with ASA is generally given for six to 12 months following percutaneous coronary intervention (PCI) with stenting, with the aim of preventing stent thrombosis and major adverse cardiac and cerebrovascular events (MACCEs). However, debate is ongoing about the optimal duration of DAPT. Of note, patient characteristics may be an important factor in treatment duration decisions. In some settings, DAPT for less than six months may be appropriate (e.g., patients with high risk of bleeding), while other patients may derive greater benefit from extended DAPT, i.e., duration beyond 12 months (e.g., high risk of stent thrombosis and low risk of bleeding).
Current guidelines recommend tailoring the length of DAPT depending on patient characteristics. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend DAPT for six months following PCI for patients with stable coronary artery disease and for 12 months in patients with acute coronary syndrome (ACS), with the consideration of extended DAPT beyond 12 months if potential thrombotic risk is high and bleeding risk is deemed low. Particularly, the use of the DAPT score as a potential means of identifying high-risk patients was emphasized. Similarly, the European Society of Cardiology (ESC) updated guidelines in 20173 also support a one-year minimum duration of DAPT for patients with ACS. Recent Canadian guidelines support an individualized approach to selecting DAPT duration, with different recommendations for patients with ACS or non-ACS indications at the time of PCI.
Given the risk of developing stent thrombosis and de-novo recurrent ischemic events, evidence assessing the impact of extending the duration of DAPT beyond 12 months has been increasing during the last few years. Clinicians need to consider the potential benefits of extended DAPT alongside the associated bleeding risk to identify patients who are most likely to benefit. Also, in some jurisdictions, reimbursement of P2Y12 inhibitors after coronary stenting may be limited to 12 months, particularly reimbursement of prasugrel and ticagrelor. Accordingly, in 2018, CADTH undertook a systematic review of relevant randomized clinical trials (RCTs); a cost-utility analysis was also conducted to complement that work. Results from both assessments are available in a science report. Findings from this work were considered by the CADTH Canadian Drug Expert Committee (CDEC) to develop the recommendations that follow.
November 20, 2018 Meeting — Committee Members
Dr. James Silvius (Chair), Dr. Ahmed Bayoumi, Dr. Bruce Carleton, Mr. Bob Gagne, Dr. Ran Goldman, Dr. Allan Grill, Dr. Peter Jamieson, Mr. Allen Lefebvre, Ms. Heather Neville, Dr. Rakesh V. Patel, Dr. Emily Reynen, Dr. Yvonne Shevchuk, and Dr. Adil Virani.
Note: Two external clinical experts who are practising as interventional cardiologists participated in the discussion, but did not vote on the recommendations.
Regrets
Dr. Alun Edwards
Conflicts of Interest
None
January 15, 2019 Meeting — Committee Members
Dr. James Silvius (Chair), Dr. Ahmed Bayoumi, Dr. Bruce Carleton, Dr. Alun Edwards, Mr. Bob Gagne, Dr. Ran Goldman, Dr. Allan Grill, Dr. Peter Jamieson, Mr. Allen Lefebvre, Ms. Heather Neville, Dr. Rakesh V. Patel, Dr. Emily Reynen, Dr. Yvonne Shevchuk, and Dr. Adil Virani.
Regrets
None
Conflicts of Interest
None
Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.
Suggested citation:
Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: Clinical and Economic Impact of Standard Versus Extended Duration — Recommendations. Ottawa: CADTH; 2019 Mar. (CADTH Optimal Use Report; vol. 9, no. 2c).
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