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| __NOTOC__
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| {{CMG}}; {{AE}}{{DN}}
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| ==Overview==
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| Dual antiplatelet therapy (or DAPT) refers to the combination of [[aspirin]] and a P2Y12 receptor antagonist. DAPT is approved for [[SIHD]] and interventions for [[ACS]], such as stent placement following [[PCI]] or [[CABG]]. The duration of treatment with DAPT for each of these categories differs and guidelines for treatment have been updated in the ''2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease''. Much of the studies done on DAPT compared the use of different types of P2Y12 receptor antagonists, the dosage of drugs, as well as the duration of treatment. The current consensus is that the use of DAPT is associated with decreased risk of [[stent thrombosis]], [[MI]] and [[stroke]]. However, the benefits of treatment should be weighed against the increased risk of major bleeding in certain patient populations.
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| ==Types and Dosage of Drugs==
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| ===Aspirin===
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| [[Aspirin]] 81 mg once daily (range 75-100 mg) is used in all patients with [[SIHD]], stent placement following [[PCI]] or [[CABG]]. The use of [[aspirin]] should be continued indefinitely.
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| ===P2Y12 Inhibitors===
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| There are several P2Y12 inhibitors currently on the market and they are given in the following doses:
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| *[[Clopidogrel]]: 75 mg once daily
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| *[[Ticagrelor]]: 90 mg once daily
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| *[[Prasugrel]]: 10 mg once daily
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| The drug of choice and duration of treatment depends on the medical condition and current recommendations.
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| ==Recommendations==
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| The 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease includes recommendations for [[ACS]] treated with medical therapy and/or [[PCI]], [[ACS]] treated with [[CABG]], as well as [[stable ischemic heart disease]]:
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| *[[Unstable angina/NSTEMI Antiplatelet therapy recommendations#2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease (Updating the 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT))|Unstable Angina/ NSTEMI Treated with Medical Therapy Alone]]
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| *[[ST elevation myocardial infarction anticoagulant and antithrombotic therapy#2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease|STEMI Treated with Medical Therapy Alone]]
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| *[[Pharmacotherapy to Support PCI#2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease|Following PCI]]
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| *[[Unstable angina / non ST elevation myocardial infarction recommendations for CABG#2016 ACC/AHA guideline focused update on duration of antiplatelet therapy in patients with coronary artery disease|CABG for NSTEMI]]
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| *[[ST elevation myocardial infarction coronary artery bypass grafting#2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease|CABG for STEMI]]
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| *[[Chronic stable angina revascularization adjunctive pharmacotherapy for percutaneous coronary intervention#2016 ACC/AHA Guideline focused update on duration of dual antiplatelet therapy (DAPT) in Patients with coronary artery disease|Stable Ischemic Heart Disease]]
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| ==The DAPT score==
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| The DAPT score is a risk score derived from the ''DAPT Trial''. It has been designed as a helpful tool for the continuation of dual antiplatelet therapy following [[PCI]] and the insertion of a drug-eluting stent ([[DES]]). A low DAPT score is associated with a higher risk of bleeding and a smaller reduction in ischemia. On the other hand, a high DAPT score translates into a greater reduction in ischemia, with a smaller risk of bleeding. The cut-off point has been set at the value of 2, such that a score of ≥2 is associated with a favorable benefit-to-risk ratio for prolonged DAPT, while a score of less than 2 is associated with an unfavorable benefit-to-risk ratio.
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| {| style="border: 0px; font-size: 90%; margin: 3px;" align=center
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| ! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Variable}}
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| ! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Points}}
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Age ≥75 years'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | -2
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Age 65 to less than 75 years'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | -1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Age less than 65 years'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 0
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" |'''Current cigarette smoker'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Diabetes Mellitus]]'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''[[MI]] at presentation'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Prior [[PCI]] or prior [[MI]]'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Prior [[PCI]] or prior [[MI]]'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''Stent diameter less than 3mm'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Paclitaxel]]-eluting stent'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 1
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''[[CHF]] or [[LVEF]] less than 30%'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 2
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| |-
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| | style="padding: 5px 5px; background: #DCDCDC;" | '''[[Saphenous vein]] graft [[PCI]]'''
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| | style="padding: 5px 5px; background: #F5F5F5;" | 2
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| |-
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| |}
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| ==''The DAPT trial''==
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| ''The DAPT trial'' published in 2014 compared the duration of DAPT following [[DES]] implantation. The study compared the standard 12 month therapy versus 30 months of DAPT. Results showed decreased risk of stent thrombosis, [[MI]] and [[stroke]] with prolonged DAPT. However, those benefits were counterbalanced by an increased risk of major bleeding. Patients with a ''DAPT score'' of ≥2 can be considered for prolonged therapy. In addition, it has been suggested that patients with a complex [[PCI]] might benefit from extended duration of DAPT therapy, as those patients are more likely to undergo revascularization or suffer from stent thrombosis. A complex [[PCI]] is a procedure with one or more of the following angiographic findings:
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| *3 vessels treated
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| *≥3 stents implanted
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| *Bifurcation with 2 stents implanted
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| *Total stent length of more than 60mm
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| *Chronic total occlusion as target lesion
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| ==''The PEGASUS-TIMI 54 Trial''==
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| ''The PEGASUS-TIMI 54 Trial'' published in 2015 looked at the long-term use of [[ticagrelor]] in addition to [[aspirin]] for 1-3 years following an [[acute coronary syndrome]]. The study compared the use of placebo versus [[ticagrelor]] at 60 and 90mg doses. While the use of [[ticagrelor]] at either dose was superior to placebo in the primary efficacy end-point, which was a composite of [[MI]], [[stroke]] and [[cardiovascular]] death, it was associated a higher primary safety end point, which was major bleeding. Comparing 60mg to 90mg of [[ticagrelor]], the 60mg dosage offered a better safety profile and fewer side effects of bleeding, [[dyspnea]] and attacks of [[gout]]. However, the results were not statistically significant.
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| ==References==
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| {{reflist|2}}
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| {{WH}}
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| {{WS}}
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