ESC Releases Revamped DAPT Guidance Focusing on Personalized Approach

BARCELONA, Spain—An overarching message of the European Society of Cardiology (ESC)’s new focused update on dual antiplatelet therapy (DAPT) is that treatment needs to be tailored to the circumstances of individual patients, according to the chair of the task force that developed the guidance.

“There is no one-size-fits-all regimen,” Marco Valgimigli, MD (Bern University Hospital, Switzerland), told TCTMD here at ESC Congress 2017, where the document was released and discussed over several sessions.

“The bleeding risk of the patient should be always assessed before deciding upon the DAPT type and duration, and that should really dominate—together with ischemic risk—decision-making with respect to duration,” he said, adding that “dynamic reassessment” of those risks should be employed. “This assessment cannot be static. You cannot just evaluate the patient once. You keep following the patient up, and if that risk is changing over time, you need to change your prescription accordingly.”

The authors say use of risk tools, including the DAPT and PRECISE-DAPT scores, may be considered to help with that personalized approach.

We tried to give practical recommendations to the practitioners. Marco Valgimigli

The new guidance, which revises recommendations from several of the society’s guidelines and brings them together in one stand-alone document, is designed to address areas of uncertainty, particularly regarding the appropriate duration of DAPT, which has been an area of extensive research and debate in recent years.

A unique aspect of this focused update is that it is accompanied by a companion article describing 18 common clinical scenarios—culled from dozens submitted by members of the medical community—and what should be done based on the new guidance, Valgimigli said.

 “We tried to give practical recommendations to the practitioners,” he said. “That is quite useful. I think the community can really take advantage of it.”

Detailed Advice on Various Scenarios

The focused update covers a lot of ground, addressing use of risk stratification tools; therapy after PCI, in patients undergoing cardiac surgery, and in those with medically managed ACS; treatment in patients with indications for oral anticoagulation; how to handle elective noncardiac surgery in patients on DAPT; and what to do in specific populations, including women, patients with diabetes, and those who have bleeding complications during treatment.

In what Valgimigli called “a major paradigm shift,” the guidelines have moved away from consideration of stent type when making decisions about DAPT type and duration. If a patient is suitable for just 30 days of DAPT because of an excessive bleeding risk, that would not justify use of BMS, which have been shown to be inferior to DES, he said. “So there is no more justification according to our guidelines to have a bare-metal stent implanted. Probably the only justification left is money, the cost of the device, and nothing else.”

Valgimigli highlighted other aspects of the new guidance:

• Recommendations regarding pretreatment have been modified, with more detailed guidance on choosing between specific P2Y12 inhibitors.
• More liberal use of proton pump inhibitors to mitigate bleeding risk—rather than restricting recommendations to patients with high risk for GI bleeding—is now advised.
• The interval required to wait after PCI before considering elective noncardiac surgery requiring discontinuation of P2Y12 inhibitors has been shortened to at least 1 month (from at least 6 months).
• In patients undergoing elective noncardiac surgery or nonemergent cardiac surgery, discontinuation of ticagrelor should be considered at least 3 days before surgery (down from 5 in prior guidance). The recommended intervals remain 5 days for clopidogrel and 7 for prasugrel.
• For the first time, there is a recommendation for ticagrelor over the other P2Y12 inhibitors in patients with MI and high ischemic risk who have tolerated DAPT without a bleeding complication. In that group, ticagrelor for longer than 12 months along with aspirin “may be preferred” over clopidogrel or prasugrel.
• The guidance opens the door to dual antithrombotic therapy in patients with an indication for oral anticoagulation, by saying that treatment with clopidogrel and an oral anticoagulant should be considered as an alternative to 1 month of triple therapy that includes aspirin in patients with a bleeding risk exceeding the ischemic risk.

Visual algorithms have been introduced to aid clinicians in switching between oral P2Y12 inhibitors; selecting the appropriate DAPT duration in various scenarios; managing patients with an indication for oral anticoagulation undergoing PCI; interrupting P2Y12 inhibitors after PCI for elective noncardiac surgery; and handling bleeding during DAPT with or without oral anticoagulation.

The focused update, which was developed in collaboration with the European Association for Cardio-Thoracic Surgery, was published in the European Heart Journal and the European Journal of Cardio-Thoracic Surgery.