ABC | Volume 113, Nº1, July 2019

Statement Statement on Antiplatelet Agents and Anticoagulants in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(1):111-134 Table 4 – Recommendation for managing patients who require oral anticoagulation undergoing percutaneous coronary intervention Indications Grade of recommendation Level of evidence The CHA 2 DS 2 -VASc score should be used to evaluate the need for maintaining anticoagulation, and the HAS-BLED score should be used to calculate the risk of bleeding IIa C During PCI, priority vascular access should always be radial, and femoral access should only be performed in exceptional cases. IIa C Triple therapy should be considered for the shortest time possible, due to the high associated risk of hemorrhage. IIa C Utilization of NOAC should be given preference over warfarin, due to the predictability of their effect. IIa C When opting to use warfarin, INR should be maintained close to 2.0. IIa C Clopidogrel should only be used once coronary anatomy has been defined and coronary angioplasty with stent placement has been indicated, and routine pre-PCI administration should be avoided. IIa C The use of prasugrel or ticagrelor is contraindicated in this situation. III C ASA should always be used at a minimum dose, preferably ≤ 100 mg daily. IIa C The use of proton pump inhibitors as prophylaxis against stress ulcers in this group of patients should be the first choice considered, due to the elevated risk of gastrointestinal bleeding. IIa C Triple therapy should be considered for patients with low hemorrhage risks during the shortest time possible (preferably 1 month, with the possibility of extending up to 6 months). After this period, anticoagulant use in combination with just one antiplatelet agent should be maintained. IIa B When there is a high ischemia risk as well as a high hemorrhage risk, the recommendation is to use triple therapy for, at most, 1 month or to begin dual therapy with an anticoagulant and clopidogrel directly. IIa B In patients with high risks of bleeding and low ischemia risks, dual therapy with an anticoagulant and clopidogrel should be initiated from the beginning. IIa A When opting to use NOAC, the combination of dual therapy with clopidogrel 75 mg daily and rivaroxaban 15 mg daily or dabigatran 110 mg twice daily should be the first choice. IIb B Discontinuation of antiplatelet therapy should be considered after 12 months. IIa B ASA: acetylsalicylic acid; INR: international normalized ratio; NOAC: new oral anticoagulant; PCI: percutaneous coronary intervention. thrombosis in second-, third-, and fourth-generation drug- eluting stents has considerably reduced with modernization of the drugs eluted and the materials utilized. This has, thus, made it possible for dual therapy duration to be as short as possible, seeing that the risk of bleeding does not justify the small absolute benefit of reducing very late thrombosis. The use of first-generation drug-eluting stents is already infrequent in Brazil. For this reason, these guidelines do not include a discussion of treatment duration following percutaneous implantation of this type of stent. The use of bioresorbable stents is already a reality in some centers. There are no studies to determine the ideal dual antiplatelet therapy duration specifically for this type of stent, although the recommendation for treatment duration is approximately 12 months. Some meta-analyses have suggested a lower rate of thrombosis in this type of stent in comparison with drug-eluting stents during the first 30 days following implantation. Use of the most potent P2Y 12 inhibitors is thus indicated for this patient profile. There is still an increased risk of very late thrombosis, and longer treatment (more than 12 months) may consequently be considered for patients with low bleeding risks. Specific studies, however, are still lacking to reinforce this recommendation. 28-31 3.2. Risk Scores There are several known risk factors related to higher risks of ischemic events and bleeding episodes. Some of these factors are also related to both situations, which makes the medical decision even more complex. Internationally implemented risk scores are currently available to aid in weighing treatment extension, taking the risk of bleeding and the benefit of reduced atherothrombotic risk into consideration. 32,33 Based on studies, 2 scores have been elaborated: the DAPT score and the PRECISE-DAPT score. The DAPT score (Table 5) was developed based on analysis of 11,648 patients included in the Dual Antiplatelet Therapy Study (DAPT) trial, and it has been validated in 8,136 patients who participated in the Patient Related Outcomes with Endeavor vs. Cypher Stenting (PROTECT) trial. Nine factors were identified: age, heart failure (HF) or reduced left ventricular ejection fraction (LVEF), saphenous vein graft stent implantation, AMI at initial presentation, prior AMI or prior PCI, paclitaxel-eluting stent, diabetes, stent diameter < 3 mm, and current tobacco use, resulting in a sum of points varying from −2 to +10. Patients with high DAPT scores (≥ 2) receive more benefits from prolonged dual antiplatelet therapy, as evaluated in cited study, over an average period of 117