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The American College of Cardiology and the American Heart Association curbed the recommended minimum course of dual antiplatelet therapy (DAPT) for some patients with coronary artery disease (CAD) in updated guidelines.

The focused update for patients getting "newer-generation stents and, in general, only to those not treated with oral anticoagulant therapy" recommended:

• Clopidogrel (Plavix) therapy for a minimum of 6 months for patients treated with drug-eluting stents (Class I)
• Clopidogrel, prasugrel (Effient), or ticagrelor (Brilinta) for 12 months in those with acute coronary syndrome (ACS, Class I)
• Extended DAPT continuation in patients who have low bleeding risk (Class II)
• Shorter duration of DAPT for patients at lower ischemic risk with high bleeding risk; longer DAPT periods for patients at elevated ischemic risk with lower bleeding risk
• Indefinite daily dosing with 81-mg aspirin in patients treated with DAPT (Class I)

Notably, the updated guidelines "are now similar for patients with non-ST-segment elevation-ACS and ST-segment elevation myocardial infarction (STEMI), as both are part of the spectrum of ACS," lead author , of Michael E. DeBakey VA Medial Center in Houston, and colleagues wrote online in the Journal of the American College of Cardiology.

According to , of Brigham and Women's Hospital in Boston and a member of the writing committee, the "use of DAPT is essential after coronary stents, but how long to give it involves assessing the balance of risks and benefits for individual patients over time. While a multitude of new analyses and clinical trials have been released recently, to the practicing clinician decision-making remains complex. The focused update provides an overview of the existing data and guidance in how to navigate decision-making."

As to why these recommendations are coming out now, Mauri told 麻豆传媒 in an email:

"Up until recently, there was very little randomized trial data to guide what duration of DAPT should be used in patients with coronary stents. While in the first months to year after heart attack or coronary stents, these medicines are very beneficial, there had been uncertainty about the balance of risk and benefit in later follow-up."

The randomized DAPT study, on which Mauri was a co-author, provided some answers by showing that an additional 18 months of DAPT after getting a drug-eluting stent reduced stent thrombosis and major adverse cardiovascular events compared with 12 months of DAPT and aspirin alone thereafter (hazard ratios 0.29 and 0.71, both P<0.001).

Mauri noted that these findings and others over the past 2 years have culminated in the development of the DAPT Score "as a way to help guide treatment to those most likely to be helped by continuing the medication, and avoid it in those who might have a higher risk of bleeding than heart attack."

The updated guidelines listed several factors that are tied to a higher DAPT score such that they tip the scales in favor of prolonged treatment: diabetes mellitus, current cigarette use, prior percutaneous coronary intervention (PCI) or prior myocardial infarction (MI), presentation with MI, congestive heart failure, vein graft PCI, and smaller stent diameter.

Current literature, on the other hand, suggests that "patients who also need anticoagulants for atrial fibrillation, who have had recent bleeding, or are at high bleeding risk may not be appropriate for longer-term treatment," Mauri wrote.

"While some decisions are simple, 'one size fits all' doesn't always work," she concluded.

"There is not one single response to the question of duration," agreed Gilles Montalescot, MD, PhD, of Pitié-Salpêtrière University Hospital in Paris, who served as a reviewer of the focused update.

In fact, "the true optimal duration remains unknown in many circumstances," Montalescot told 麻豆传媒 in an email. These recommendations "represent a global view that you can override with your own judgment of an individual case," he emphasized.

The guidelines were developed in collaboration with the American Association for Thoracic Surgery, American Society of Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons and also endorsed by the Preventive Cardiovascular Nurses Association and Society for Vascular Surgery.

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