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Current Antiplatelet Treatment During and After Percutaneous Coronary Intervention Gregory Pavlides, MD, FACC, FESC Director, First Cardiology Division and Chairman, Cardiology Department Onassis Cardiac Surgery Center Athens


Antiplatelet Therapy During and After Percutaneous Coronary Intervention 

Antiplatelet treatment is an essential part of percutaneous coronary intervention (PCI), both during the procedure and for a longer-term period after that.

This adjunctive therapy has evolved in parallel with the evolution of PCI itself.

Currently, dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine is used for the procedure and up to a year or longer after that.

The dose of DAPT and the duration of treatment after PCI depends on the clinical setting and the type of stent.


The central role of platelets in the pathophysiology of acute coronary syndromes and PCI has determined the need for the current dual anti-platelet therapy.


Balloon Angioplasty and Stenting Effects that Activate Platelets and the Mechanism of Thrombosis 

Trauma of the arterial wall

Loss of endothelial cell barrier capacities

Exposure of subendothelial extracellular matrix and lipid core components to blood flow

Bare metal on the wall


Dual Antiplatelet Treatment After ACS Treated With PCI Sabatine et al: JAMA 2005


LOADING DOSE OF CLOPIDOGREL


Long-Term DAPT (ASA + Clopidogrel). Issues of Treatment to be Clarified 

Prevention of target- versus non-target lesion related events

Relationship between DAPT discontinuation and stent thrombosis (ST)

 

Balancing efficacy with bleeding risk Can DAPT suppress all events regardless of cause?

Alternative antiplatelet agents


Kaplan-Meier Curves for the Primary End Point in Patients With CAD Either With or Without Prior MI

Preventive Benefit of DAPT CHARISMA Trial

Bhatt, D. L. et al. J Am Coll Cardiol 2007;49:1982-1988

Copyright Š2007 American College of Cardiology Foundation. Restrictions may apply.


Main Benefit of DAPT After DES-PCI. Prevention of Stent Thrombosis


Recent Studies Changing Current Practice on Dose and Duration of DAPT   

CURRENT-OASIS 7 TRITON-TIMI 38 PLATO


Higher Clopidogrel and ASA Doses


Alternative Agents


Characteristics of Currently Available Antiplatelet Agents


Conclusions 

The evidence for using dual antiplatelet therapy (100 mg of ASA + 75 mg of clopidogrel) in patients with ACS is very well established. Initial high-dose clopidogrel seems to be beneficial Duration of treatment should be at least 1 year, unless the clinical picture dictates otherwise Most of the cases of stent thrombosis occur the first 6 months, so DAPT can be interrupted after 6 months, especially if 2nd or 3rd generation DES has been used Long-term treatment rather exerts a secondary prevention effect, than preventing target lesion events Prasugrel is preferable in ACS patients with AMI or DM, if there is no increased bleeding rirk Ticagrelor offers better protection also, with less bleeding risk


Pavlides