ABC | Volume 113, Nº1, July 2019

Statement Statement on Antiplatelet Agents and Anticoagulants in Cardiology – 2019 Arq Bras Cardiol. 2019; 113(1):111-134 Figure 1 – Flowchart representing indications for antithrombotic therapy combinations in accordance with ischemic and hemorrhagic risk. C: clopidogrel; OAC: oral anticoagulant; PCI: percutaneous coronary intervention. Patient who requires OAC undergoing PCI High risk of hemorrhage Low risk of hemorrhage Low risk of ischemia High risk of ischemia Dual therapy C + OAC for 12 months Start with dual therapy C + OAC for 30 days Start with triple therapy ASA + C + OAC for 30 days OR Dual therapy C + OAC or ASA + OAC between 1 and 12 months Triple therapy ASA + C + OAC for 1 to 6 months Dual therapy C + OAC or ASA + OAC between 6 and 12 months Maintain only OAC after 12 months 1 month 6 months 12 months 30 months, given the reduction in AMI, stent thrombosis, and cardiovascular and cerebrovascular events, at the expense of a small increase in the risk of bleeding (NNT = 34 versus NNH = 272). On the other hand, patients with low DAPT scores (< 2) have an increased risk of events related to bleeding, with no reduction in the rate of cardiovascular and cerebrovascular events (NNH 64). 32 The Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) included 14,963 patients undergoing elective, urgent, or emergency PCI, randomized into long (12 to 24 months) or short (3 to 6 months) dual antiplatelet therapy durations, with relation to bleeding risk based on 5 factors: age, creatinine clearance, hemoglobin, white-blood- cell count, or prior spontaneous bleeding (calculator available at www.precisedaptscore.com ). In patients with high PRECISE- DAPT scores (≥ 25), prolonged therapy was associated with higher bleeding rates and no ischemic benefits; in contrast, patients with low PRECISE-DAPT scores had low combined adverse ischemic events with no significant increase in risk of bleeding. 33 Table 5 – Factors used to calculate DAPT score. Scores ≥ 2 are associated with favorable risk-benefit, whereas scores < 2 are associated with unfavorable risk-benefit Age ≥ 75 Points Age > 65 and < 75 –2 Age < 65 –1 Current tobacco use 0 Diabetes mellitus 1 AMI at initial presentation 1 Prior PCI or AMI 1 Stent diameter < 3 mm 1 Paclitaxel-eluting stent 1 HF or reduced LVEF 1 Saphenous vein graft PCI 2 ICP em enxerto de veia safena 2 AMI: acute myocardial infarction; HF: heart failure; LVEF: left ventricular ejection fraction; PCI: percutaneous coronary intervention. 118