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 6 – Recommendations on duration of dual antiplatelet therapy following percutaneous coronary intervention in stable coronary artery disease Indications Grade of recommendation Level of evidence In patients with stable CAD undergoing PCI who need dual antiplatelet therapy, the preferred combination is clopidogrel (75 mg) and a dose of ASA (75 to 200 mg) I A The use of drug-eluting stents is always preferable to conventional stents, regardless of dual antiplatelet therapy duration I A In patients with stable CAD undergoing PCI with a drug-eluting stent, dual antiplatelet therapy should be maintained for a minimum period of 6 months, regardless of stent type I A In patients with stable CAD undergoing PCI with a conventional stent, dual antiplatelet therapy may be maintained for a minimum period of 1 month when there is a high risk of bleeding I A In patients with stable CAD undergoing PCI with a drug-eluting stent who have high bleeding risks, the suspension of dual antiplatelet therapy may be considered IIa B In patients with stable CAD undergoing PCI with a drug-eluting stent who tolerate the routine dual antiplatelet therapy duration without bleeding episodes and who have low bleeding risks and high atherothrombotic risks (DAPT score ≥ 2 and PRECISE-DAPT < 25), it is possible to maintain antiplatelet therapy for > 12 months and ≤ 30 months IIb A ASA: acetylsalicylic acid; CAD: coronary artery disease; PCI: percutaneous coronary intervention. Scientific evidence tested in randomized studies is lacking to evaluate the real value of these scores in improving long- term outcomes for patients receiving dual antiplatelet therapy and undergoing PCI. Nevertheless, their utilization may be considered when individualizing decisions and contemplating the risks and benefits of prolonging dual antiplatelet therapy. 3.3. Dual Antiplatelet Therapy Duration following Percutaneous Coronary Intervention for Stable Coronary Artery Disease Dual antiplatelet therapy in stable cases of CAD is not routinely indicated for patients receiving clinical treatment. It is only effectively necessary to indicate this following PCI, and the combination of ASA and clopidogrel is preferable. There is no evidence from randomized studies on the use of prasugrel and ticagrelor as on option over clopidogrel for this patient profile. They are, however, options which may be considered for patients with high atherothrombotic risks if there is evidence that clopidogrel is not effective based on previous clinical outcomes or for patients who receive implantation of a bioresorbable stent. Of the studies that evaluate dual antiplatelet therapy duration (ASA and clopidogrel) in stable patients, 3 are more recent, and they compare 6 months with 12 to 24 months of treatment. The Safety and Efficacy of 6 Months Dual Antiplatelet Therapy after Drug Eluting Stenting (ISAR-SAFE) study, 34 which was the largest, randomized 4,005 patients and confirmed that there are no benefits and no reduction in ischemic events with the use of dual antiplatelet therapy for 12 months in comparison with 6 months. Similar results were also found in the Is There a Life for DES after Discontinuation of Clopidogrel? (ITALIC) 35 and Second Generation Drug-eluting Stent Implantation followed by Six- versus Twelve-month Dual Antiplatelet Therapy (SECURITY) studies. 36 Other meta-analyses 37,38 have shown that 12 months of therapy did not add benefits in relation to reduced ischemic events in comparison with shorter therapy duration (< 6 months, including evaluation of studies that analyzed 3 months of therapy), which may be an option for patients with lower bleeding risks. The DAPT trial and other meta-analyses 37-39 have demonstrated that, in addition to reduced ischemic events, stent thrombosis, and infarction rates, as well as increased bleeding rates, therapy prolonged for more than 12 months showed a possible, albeit weak, relation to increased general mortality. The recommendation of these guidelines is, thus, based on average dual antiplatelet therapy duration of 6 months following PCI in stable patients, with the possibility of considering a period of 3 months for patients with high bleeding risks. More prolonged use (> 12 months) is not routinely indicated and may be considered in accordance with the patient’s clinical and anatomical profile (Table 6). 3.4. Dual Antiplatelet Therapy Duration following Percutaneous Coronary Intervention for Acute Coronary Artery Disease Ticagrelor and prasugrel are preferential P2Y 12 inhibitors for patients undergoing PCI after ACS. In patients who have ACS, the ischemia risk continues to be higher until approximately 1 year after the event, even after the culprit and non-culprit lesions have been treated. 22,20,40,41 The main studies which affirm that ticagrelor and prasugrel have benefits over clopidogrel consider a reduction in events with an average treatment duration of 12 months. A meta-analysis of 3 studies which compared 3, 6, and 12 months of dual therapy, including 11,473 patients, 4,758 of which had ACS, demonstrated that dual antiplatelet therapy for ≤ 6 months was associated with an increased risk of infarction, which was, however, not statistically significant. Considering the lower number of acute patients in comparison with studies that demonstrated the real benefits of intense dual antiplatelet therapy with ticagrelor and prasugrel (TRITON 119