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  • The ESC update emphasizes the need for

    2020-09-15

    The 2017 ESC update emphasizes the need for implementing strategies to minimize PCI-related complications, including risk stratification for ischemia and bleeding, keeping triple antithrombotic therapy to the shortest possible duration with dual antithrombotic therapy as an alternative, using non–vitamin K antagonist oral anticoagulants whenever possible instead of vitamin K antagonists (at the lowest approved dose effective for stroke prevention tested in atrial fibrillation trials when combined with antiplatelet drugs [COR IIa, LOE C]), considering an INR in the lowest part of the therapeutic range in case of warfarin use (COR IIa, LOE C), and using proton pump inhibitors routinely (7). For patients in whom concerns about the risk of ischemic complications prevail, 1 month of triple antithrombotic therapy with OAC, aspirin, and clopidogrel should be recommended irrespective of the type of stent used (COR IIa, LOE B), but may be considered up to 6 months in patients who are at high ischemic risk due to ACS or other anatomical/procedural characteristics that outweigh the risk of bleeding (COR IIa, LOE B). When the Compound C of triple antithrombotic therapy is concluded, a dual antithrombotic regimen with OAC and aspirin or clopidogrel should be recommended up to 12 months (COR IIa, LOE A), followed by OAC alone (COR IIa, LOE B). In patients where concerns about the risk of bleeding complications prevail, triple antithrombotic therapy should not be prolonged beyond 1 month (COR IIa, LOE B) and should be even avoided using double antithrombotic therapy with OAC and clopidogrel as an alternative (COR IIa, LOE A). When rivaroxaban is used in combination with aspirin and/or clopidogrel, the 15-mg once-daily dose of rivaroxaban may be used instead of the conventional 20-mg once-daily dose (COR IIb, LOE B). The use of ticagrelor or prasugrel is not recommended as part of triple antithrombotic therapy (COR III, LOE C).
    New Evidence and Ongoing Studies Several randomized clinical trials have been published after the release of the ACC/AHA and ESC updates on DAPT, which have the potential to influence or inform the COR and/or reinforce the relative LOE, and other trials are ongoing (Figure 5). A description of trials looking at alternative antithrombotic strategies, such as the adjunctive use of oral anticoagulant therapy, goes beyond the scope of this section and is described elsewhere 65, 66.
    Conclusions The rapid evolution of the field of antithrombotic pharmacotherapy, in an ever-changing landscape of safer stents, bleeding avoidance strategies, and newer drugs for secondary prevention, requires regular updates of recommendations for DAPT. Indeed, the risk-benefit of DAPT depends on many individual circumstances, including the clinical scenario and the susceptibility to ischemia, bleeding, or both. The current ACC/AHA and ESC updates for DAPT are substantially similar with respect to key recommendations on P2Y12 inhibitor selection and DAPT duration. However, whereas the 2016 ACC/AHA update is essentially centered around the topic of DAPT duration, the ESC document has a broader focus on antiplatelet therapy in general and relative to specific clinical scenarios (Table 4). Nevertheless, a common and important theme in both updates is the shift from a population-based treatment approach to one that is more “patient-centered.” Indeed, this is a step toward an emerging approach for disease treatment and prevention called “precision medicine,” which takes into account individual variability in genes, environment, and lifestyle for each person. Although the evidence generated since the publication of the ACC/AHA and ESC updates seems unlikely to provoke breakthrough changes with respect to existing recommendations, ongoing studies will define new areas of interest and possibly lead to modifications in future recommendations to better personalize patient care.