Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: Clinical and Economic Impact of Standard Versus Extended Duration [Internet]

Excerpt

Dual antiplatelet therapy (DAPT) — the combination of a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) together with ASA — is routinely given following percutaneous coronary intervention (PCI) with stenting, with the aim of preventing stent thrombosis and other major adverse cardiac and cerebrovascular events (MACCEs). Current guidelines recommend tailoring the length of DAPT, depending on individual patient characteristics. Prescribing DAPT for six to 12 months is generally accepted as being standard practice following PCI with stenting. However, 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 over the last few years. It would appear that some benefits may be derived from such practice, although clinicians also need to consider the associated bleeding risk. It is therefore important for clinicians to identify those patients most likely to benefit from extended DAPT, as well as rule out those who may derive more harm than good from using such an approach. Also, in some jurisdictions, reimbursement of P2Y12 inhibitors after coronary stenting may be limited to 12 months, particularly reimbursement of prasugrel and ticagrelor. On the other hand, where restrictions have been lifted — in particular for clopidogrel — it may be important to ensure that extended therapy will result in optimal outcomes for patients after PCI and not result in more harm. Accordingly, given the current uncertainty about the benefits and harms of extended DAPT beyond one year, further elucidation of the available evidence, including the assessment of both the clinical and economic impact, is required to inform health care decision-makers, policy-makers, clinicians, and patients.