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Review
. 2019 Dec;42(12):1170-1180.
doi: 10.1002/clc.23275. Epub 2019 Oct 14.

Critical appraisal of guidelines for coronary artery disease on dual antiplatelet therapy: More consensus than controversies

Shaozhao Zhang  1   2 , Huimin Zhou  1   2 , Xiaodong Zhuang  1   2 , Daya Yang  1   2 , Xiuting Sun  1   2 , Xiangbin Zhong  1   2 , Xiaoyu Lin  3 , Xun Hu  1   2 , Yiquan Huang  1   2 , Xinxue Liao  1   2 , Zhimin Du  1   2
Affiliations
Review

Critical appraisal of guidelines for coronary artery disease on dual antiplatelet therapy: More consensus than controversies

Shaozhao Zhang et al. Clin Cardiol. 2019 Dec.

Abstract

Background: Dual antiplatelet therapy (DAPT) in the form of aspirin plus a P2 Y12 inhibitor, when indicated, is one of the key treatments in coronary artery disease (CAD). Many recommendations on DAPT in patients with CAD based on current guidelines are largely inconsistent. In our current study, we aimed at systematically reviewing DAPT-relevant clinical practice guidelines, and highlighting their commonalities and differences for better informed decision-making.

Methods: Contemporary guidelines in English were searched in MEDLINE, Embase and websites of guideline organizations and professional societies. Guidelines with recommendations on DAPT for CAD patients were included. Guideline quality was appraised with the 6-domain Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The reporting of conflicts of interest (COI) was assessed individually with supplementary items from the RIGHT (Reporting Item for Practice Guidelines in Healthcare) checklist. Meanwhile, extraction of recommendations was performed.

Results: A total of 18 guidelines fulfilled our inclusion criteria. Most of them were graded with relatively good scores averaging from 42% to 74%. Domains for lower scores were in "stakeholder involvement" and "application." The reporting of COI was satisfactory. For the recommendations on DAPT, most guidelines with high AGREE II scores included consistent recommendations on the timing and P2 Y12 inhibitor selection. Nonetheless, conflicts still exist on the duration of DAPT.

Conclusions: Quality of guidelines for DAPT in CAD was relatively high, though defects existed in "Applicability" and "Stakeholder Involvement." As these guidelines developed, DAPT recommendations gradually converged on a consensus. Clinical decision should be made on an individual basis.

Keywords: AGREE II; coronary artery disease; dual antiplatelet therapy; guideline.

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Conflict of interest statement

The authors declare no potential conflict of interests.

Figures

Figure 1
Figure 1
Guidelines search and selection
Figure 2
Figure 2
AGREE II domain scores of selection guidelines. ACC, American College of Cardiology; ACCF, American College of Cardiology Foundation; AHA, American Heart Association; CCS, Canadian Cardiovascular Society; ESC, European Society of Cardiology; JCS, Japanese Circulation Society; NHFA, National Heart Foundation of Australia; NICE, National Institute for Health and Care Excellence; TSC, Taiwan Society of Cardiology
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