Update on Antithrombotic Therapy after Percutaneous Coronary Intervention

Abstract

Percutaneous coronary intervention (PCI) has become a standard-of-care procedure in the setting of angina or acute coronary syndrome. Antithrombotic therapy is the cornerstone of pharmacological treatment aimed at preventing ischemic events following PCI. Dual antiplatelet therapy as the combination of aspirin and P2Y₁₂ inhibitor has been proven to decrease stent-related thrombotic risks. However, the optimal duration of dual antiplatelet therapy, an appropriate P2Y₁₂ inhibitor, and the choice of aspirin versus P2Y₁₂ inhibitor as single antiplatelet therapy remain controversial. Furthermore, the combined use of oral anticoagulation in addition to antiplatelet therapy is a complex issue in clinical practice, such as in patients with atrial fibrillation. The key challenge concerning the optimal antithrombotic regimen is ensuring a balance between protection against thrombotic events and against excessive increases in bleeding risk. In this review article, we summarize the current evidence concerning antithrombotic therapy in patients with coronary artery disease undergoing PCI.

Keywords: antithrombotic therapy; dual antiplatelet therapy; percutaneous coronary intervention.

Figure 1.

Basic recommendations concerning the DAPT duration in patients not indicated for oral anticoagulation undergoing percutaneous coronary intervention. The American and European guidelines in 2016 and 2017 recommend DAPT for 3 to 12 months (Class I or IIa) depending on the patient characteristics. The Japanese guidelines in 2018 recommend 6- to 12-month DAPT for ACS and 1- to 3-month DAPT for stable CAD patients with HBR (3-6). ACS: acute coronary syndrome, CAD: coronary artery disease, DAPT: dual antiplatelet therapy, HBR: high bleeding risk

Figure 2.

Basic recommendations concerning antithrombotic therapy for patients indicated for oral anticoagulation after PCI. In the North American consensus document (82), the default approach is triple therapy, a combination of aspirin, clopidogrel, and an OAC for patients indicated for life-long anticoagulation treatment after PCI only during index hospitalization, followed by dual therapy with clopidogrel plus an OAC after hospital discharge. If a patient has HBR, dual therapy for up to six months is recommended. For patients with high ischemic and low bleeding risks, triple therapy for up to one month is acceptable. The Japanese guidelines’ recommendation is similar to the North American recommendation (5). The European consensus document recommends one-month triple therapy or dual therapy with an OAC plus clopidogrel as the initial strategy for HBR patients, while triple therapy for up to six months may be considered in patients with a high ischemic risk (83). A DOAC is preferred to a VKA, and clopidogrel is the basic choice of P2Y₁₂ inhibitor for triple or dual therapy. However, the North American perspective and European consensus document indicate ticagrelor as a potential alternative in patients with high ischemic and low bleeding risks. The Japanese guidelines allow prasugrel to be selected as the P2Y₁₂ inhibitor in addition to clopidogrel. HBR: high bleeding risk, OAC: oral anticoagulant, P2Y₁₂-i: P2Y₁₂ inhibitor, PCI: percutaneous coronary intervention