Antiplatelet Strategies Following PCI: A Review of Trials Informing Current and Future Therapies

Abstract

Dual antiplatelet therapy (DAPT) has been paramount in preventing thrombosis following percutaneous coronary intervention for nearly 3 decades. However, over the years, DAPT has seen significant changes in the agents utilized and duration of therapy as trials have raced to keep up with advancements made in stent technology and our understanding of bleeding and ischemic risk. Recently, there have been a number of trials demonstrating significant reductions in bleeding events with shorter DAPT durations, which are not yet reflected in practice guidelines. Further, there has been a shift toward more individualized antiplatelet regimens to meet patient-specific risk profiles. This review provides a comprehensive summary of the major trials that have informed current DAPT strategies, puts into context recent trials driving a shift toward more tailored antiplatelet regimens, and highlights gaps in knowledge that remain and the ongoing trials designed to address them.

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

Graphical abstract

Figure 1

Major societal guidelines for dual antiplatelet therapy following drug-eluting stent placement. A, aspirin; ACC, American College of Cardiology; ACS, acute coronary syndromes; AHA, American Heart Association; C, clopidogrel; DAPT, dual antiplatelet therapy; DOAC, direct oral anticoagulants; ESC, European Society of Cardiology; HBR, high bleeding risk; P, prasugrel; P2Y₁₂i, P2Y purinoceptor 12 inhibitors; PCI, percutaneous coronary intervention; T, Ticagrelor; VKA, vitamin K antagonist; SAPT, single antiplatelet therapy; SIHD, stable ischemic heart disease; LM, left main; ^∗taking into account bleeding and ischemic risk; ^†, Very high bleeding risk (bleeding in the past month and/or non-deferrable surgery); ^‡, Suggests cut-off of PRECISE-DAPT >25 to define high bleeding risk; ∗∗, Recommendation from 2020 ACC Expert Consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary interventionor with atherosclerotic cardiovascular disease. Green = Class 1, Yellow = Class 2a, Orange = Class 2b.

Figure 2

Trials of drug-eluting stents versus BMS with 1-month DAPT. BMS, bare metal stent; BP-EES, biodegradable polymer everolimus-eluting stent; CD, cardiac death; DAPT, dual antiplatelet therapy; DC-BES, drug coated balloon expandable stent; DES, drug-eluting stents; E-ZES, Endeavour zotarolimus-eluting stent; HBR, high bleeding risk; HR, hazard ratio; MI, myocardial infarction; RR, rate ratio; ST, stent thrombosis; TLR, target lesion revascularization; TVR, target vessel revascularization.

Figure 3

Major trials of dual vs triple therapy in atrial fibrillation following percutaneous coronary intervention. Afib, atrial fibrillation; Api, apixaban; ASA, aspirin; clopi, clopidogrel; CRNM, clinically relevant nonmajor bleeding; dabi, dabigatran; DAPT, dual antiplatelet therapy; Edo, edoxaban; HR, hazard ratio; ISTH, International Society on Thrombosis and Haemostasis; P2Y₁₂i, P2Y purinoceptor 12 inhibitors; PCI, percutaneous coronary intervention; riva, rivaroxaban; TIMI, thrombolysis in myocardial infarction; VKA, vitamin K antagonist. ∗noninferiority

Central Illustration

Tailored antiplatelet strategies in the contemporary drug-eluting stents era. ARC, Academic Research Consortium; CAD, coronary artery disease; CKD, chronic kidney disease; DAPT, dual antiplatelet therapy; ICH, intracranial hemorrhage; MI, myocardial infarction; MV, multivessel; OAC, oral anticoagulation; P2Y₁₂i, P2Y purinoceptor 12 inhibitors; PARIS, Patterns of nonadherence to antiplatelet regimen in stented patients; ST, stent thrombosis.