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Regarding DAPT, what are the key points and updates of the three major domestic and foreign guides? Please listen to Academician Han Yaling’s on-site interpretation!
compilation丨Yu Xiaosu
Source丨Cardiovascular Channel
Dual antiplatelet (DAPT) treatment is one of the most important treatment methods in the field of cardiovascular diseases. In recent years, guidelines have been issued at home and abroad, and evidence-based recommendations have been made for patients with coronary heart disease of different types and treatment stages.
At the 29th Great Wall International Cardiology Conference, Academician Han Yaling from the Institute of Cardiovascular Diseases of Shenyang Military Region General Hospital , the entire army, under the title of "Key Points for Updated DAPT Guidelines at Domestic and Foreign DAPT Guidelines", focused on the DAPT part of the 2016 China Percutaneous Coronary Interventional Treatment (PCI) Guidelines, the 2017 European Society of Cardiology (ESC) DAPT Guidelines, and the 2018 ESC Myocardial Revascularization Guidelines.
Figure: Academician Han Yaling’s lecture site
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2016 DAPT part of the Chinese PCI Guide
★ stable coronary heart disease (SACD) patients with antiplatelet therapy after stent placement
drug-eluting stent (DES) was placed for 6 months DAPT (IB) ; from 2006 to 2012, a CREATE study led by Academician Han Yaling showed that for SACD patients, DAPT was safe and effective for 6 months after application of coating degradable DES. The results of 5 years showed that there was no statistical difference between the incidence of major cardiovascular events and the use of DAPT for more than 6 months. This study results provide strong evidence for the duration of double antibiotics after DES in SACD patients.
0 patients with high risk of bleeding, patients with high risk of DES can consider shortening DAPT (<6>
patients with high risk of bleeding, need to undergo non-cardiac surgery that cannot be postponed, or receive oral anticoagulant treatment at the same time, DAPT (IIbC) can be given 1 to 3 months after DES is implanted;
patients with high risk of ischemia and low risk of bleeding, and DAPT can last for more than 6 months (IIbC).
★ Non-ST-segment elevation acute coronary syndrome (NSTE-ACS): Recommended ticagrelor
Recommended patients of this type should add a P2Y12 receptor antagonist on the basis of aspirin and maintain it for at least 12 months unless there is contraindication (such as high risk of bleeding) (IA). Selections include:
(1) ticagrelor: loading dose 180mg, maintenance dose 90mg, twice a day. All patients without contraindications and medium-high risk of ischemia (such as elevated troponin, including clopidogrel , are recommended to choose ticagrel (IB);
(2) clopidogrel: 600 mg of loading dose, maintaining dose 75 mg once a day, for patients without contraindications or long-term oral anticoagulant treatment (IB);
(3) When early PCI treatment is required, ticagrel is the first choice, and clopidogrel (IB); Academician Han pointed out that since ticagrel acts faster than clopidogrel, ticagrel is recommended as the first choice among patients who need to undergo PCI as soon as possible.
For patients with high risk of ischemia and low risk of bleeding, it is considered to add P2Y12 receptor antagonist on the basis of aspirin for treatment >1 year (IIbA);
In emergencies or thrombotic complications, consider using platelet glycoprotein IIb/IIIa receptor antagonist (GPI) (IIaC);
Patients with unknown coronary lesions are not recommended for GPI pretreatment (IIIA).
Add a P2Y12 receptor antagonist on the basis of aspirin and maintain it for at least 12 months unless there are contraindications (such as high risk of bleeding) (IA).Selections include:
0 The P2Y12 receptor antagonist (IB) was given during the first medical contact;
High-risk patients who are considered for emergency situations, no evidence of reflow or thrombotic complications are considered for GPI (IIaC)
to directly run PCI treatment. Academician Han emphasized that since STEMI patients have a more urgent and heavier condition than NSTE-ACS, high-risk patients during transportation can also consider using GPI.
Diabetic patients: ticagrelor is the first choice for antiplatelet therapy (loading agent 180mg, maintenance agent 90mg, twice a day), and is used in combination with aspirin for at least 12 months.
Chronic kidney disease (CKD) patients: ticagrelor is the first choice for , and the dose is not required; however, ticagrelor is less experienced in patients receiving dialysis treatment, and clopidogrel can be selected.
Patients with complex coronary lesions: ticagrelo is the first choice for .
★ ST segment elevation myocardial infarction (STEMI): Give P2Y12 receptor inhibitor
(1) Tigrelor: Patients without contraindications were given a loading dose of 180mg, a maintenance dose of 90mg, twice a day (IB); a PLATO study published in the New England Journal of Medicine (NEJM) in 2009 showed that compared with clopidogrel, ticgrelor can significantly reduce the risk of cardiovascular events in patients with ACS. Real-world research on the ACS population in China also confirmed the effectiveness and safety of ticagrelor.
(2) clopidogrel: loading dose 600 mg, maintenance dose 75 mg once a day, for those without ticagrelol or with ticagrel contraindications (IB).
★ 8 special risk groups Antithrombotic treatment: DAPT strategies for patients with atrial fibrillation are divided into 3 situations
Non-cardiac surgery patients: The adjustment of antiplatelet regimen should fully weigh the urgency of the surgical procedure and the risk of bleeding and thrombosis in patients. For patients with low risk of cardiac events, DAPT should be stopped 5 to 7 days before surgery, and medication can be reused to ensure sufficient hemostasis after surgery.
CYP2C19 slow metabolism and platelet hyperresponsiveness: If there is no high risk factor for bleeding, ticagrelor should be preferred.
SCAD with atrial fibrillation score of ≥2 points and HAS-BLED ≤2 points: It is recommended to place oral anticoagulant after metal bare stent (BMS) or new generation DES + aspirin 100mg/d + clopidogrel 75mg/d for at least 1 month and then oral anticoagulant + aspirin 100mg/d or clopidogrel 75mg/d for at least 1 month (IIaC).
For patients with ACS combined well atrial fibrillation: If the HAS-BLED score is ≤2 points, it is recommended not to consider the stent type. Oral anticoagulant + aspirin 100mg/d + clopidogrel 75mg/d for 6 months, and then oral anticoagulant + aspirin 100mg/d or clopidogrel 75mg/d for 1 year (IIaC).
HAS-BLED score ≥3 points for patients with coronary heart disease (SCAD and ACS): recommends not considering the stent type, oral anticoagulant + aspirin 100mg/d, clopidogrel 75mg/d for at least 1 month, and then oral anticoagulant + aspirin 100mg/d or clopidogrel 75mg/d (duration depends on the specific clinical situation) (IIaC).
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2
2017 ESC DAPT Guidelines Some key points
In the "ESC Guidelines for the Treatment of Double Antibody Treatment in Patients with Coronary Heart Disease" published in 2017, the guide included the PRECISE-DAPT score and DAPT score for the first time to evaluate the benefits and risks of different DAPT courses more accurately. Academician Han Yaling pointed out that these two scoring standards have their own advantages, but there is currently a lack of research data on the Chinese population.
Figure: 2017ESC-DAPT Guide Recommended Application Score Guide DAPT Treatment Selection (from Live Slide)
★ Recommended points about the selection and treatment of P2Y12 receptor inhibitors in ACS patients
For ACS patients, regardless of PCI or drug treatment, the default DAPT course should be 12 months (IA);
ACS drug treatment high Patients with bleeding risk should consider DAPT (IIaC) for at least 1 month; patients with high bleeding risk with stent placed in
ACS should consider DAPT (IIaB); patients with 6 months of DAPT (IIaB); patients with DAPT that can tolerate DAPT and have no bleeding complications may consider treatment for more than 12 months (IIaB).
★ P2Y12 receptor inhibitors recommended key points for dressing changes between
. In the emergency room:
clopidogrel → ticagrelol: ticagrel load amount 180mg, regardless of the time and dosage of clopidogrel; Academician Han pointed out that because the patient's condition was critical during emergency treatment, even if he had just taken clopidogrel half an hour ago, the load amount could be given immediately to enhance the antiplatelet effect.
ticagrelor → clopidogrel: clopidogrel load 600mg, after taking ticagrel for 24 hours;
. During chronic period:
clopidogrel→ ticagrel: ticagrel maintenance amount 90mg, bid, after taking clopidogrel for 24 hours;
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2018 Update points of the DAPT part in the ESC Revascularization Guide
★ Summary of main updates in antithrombotic treatment
. New IIa recommendation:
Non-valvular atrial fibrillation patients undergo anticoagulation and antiplatelet therapy, non-warfarin oral anticoagulant (NOAC) is better than vitamin K antagonists (VKA) (A). (Source of evidence: RE-DUAL-PCI)
. New IIb recommendation:
For patients with the first P2Y12 receptor inhibitor, Cangrelor (A) can be recommended during PC surgery ( Source: CHAMPION)
For patients with ACS who first applied P2Y12 receptor inhibitor, GPI (C) can be recommended during PCI surgery ( Source: Expert recommendation). Academician Han pointed out that the new version of the guideline emphasizes the suggestions for patients with intraoperative GPI for the first time using P2Y12 inhibitor, which is of great significance to the treatment of PCI in my country.
0 PCI post-PCI anticoagulation, recommended dabigatran 150mg is better than 110mg dose combined with monoclonal antibody treatment (A), (Source of evidence: RE-DUAL-PCI) . Studies show that the incidence of thrombosis and myocardial infarction in 150 mg of dabigatran is lower than 110 mg, but the statistical difference is not reached. Therefore, it still needs to be further confirmed whether it can be used in the Chinese population.
can be appropriately performed for lowering the treatment of P2Y12 receptor inhibitor based on platelet function in patients with ACS (A), (Source of evidence: TROPICAL-ACS) .
★ Intraoperative antiplatelet therapy in patients with SCAD
If aspirin is used at the end of the interventional treatment, it is recommended to take oral 150~300mg (or 75~250mg intravenous injection) load dose (IC);
Electric stent implantation recommended to use clopidogrel (600mg load) Dosage, 75mg/d maintenance dose) (IA);
GPI (IIaC) is considered only in emergency situations;
Ticagrelor or pragrarel may be considered for specific high-risk patients with elective PCI (such as intrastent thrombosis or left trunk stent implantation) a new addition (IIbC).
Figure: 2018ESC Revascularization Guidelines for DAPT Recommendation Points for SCAD in PCI
★ Recommendation Points for Long-term DAPT after PCI: It refers to the I LOVE IT2 DAPT subgroup study from the Chinese population
For SCAD patients treated with stent implantation, aspirin + clopidogrel is generally recommended for 6 months, regardless of stent type (IA) ; I LOVE led by Academician Han Yaling's team The results of the 5-year follow-up of the T2DAPT subgroup study showed that the safety and effectiveness of DAPT 6 months after the biodegradable polymer sirolimus-eluting stent (BP-SES) in SCAD patients were not inferior to 12 months of DAPT, providing strong "Chinese evidence" for 6 months of DAPT treatment.
3 months DAPT may have safety problems, DAPT can be considered for 1 month (IIbC).
★ NSTE-ACS Recommended DAPT for patients with PCI
aspirin + P2Y12 receptor inhibitor, for 12 months, unless there are contraindications such as high risk of bleeding (IA);
GPI (IIaC) is considered only in emergency situations, if there is no reflux or thrombosis complications;
Invasive treatment, ticagrelor (load volume 180mg + 90mg should be considered once the diagnosis is clear. Bid), or use clopidogrel (load 600mg + 75mg Qd) (IIaC) when ticagrelor is not available;
patients who have received PCI, if they have not used P2Y12 receptor inhibitor, they can consider using GPI (IIbA). This is a new recommendation for
Figure: 2018 ESC Revascularization Guidelines for NSTE-ACS DAPT recommendations for PCI patients (from live slideshow)
★ NSTE-ACS and Recommended DAPT after STEMI PCI
For ACS patients undergoing coronary stent implantation, it is recommended to add a P2Y12 receptor inhibitor on the basis of aspirin, and the application time is 12 months unless the patient has contraindications such as high bleeding risk (such as PRECISE-DAPT ≥25 points) (IA);
If patients with
ACS stents are placed in patients with high risk of bleeding (for example, PRECISE-DAPT ≥25 points), they should consider discontinuing P2Y12 receptor inhibitor treatment (IIaB) after 6 months;
P2Y12h guided by platelet function detection through P2Y12 receptor inhibitor downgrade therapy (such as switching from prasugrel or ticagrelor to chlorogradyl) is also an optional DAPT strategy, especially for ACS patients (IIbB) who are not adapted to the treatment of strong platelet inhibitors for 12 months, there is new evidence for TROPICAL-ACS study;
ACS patients can tolerate DAPT and have no bleeding and concurrent dysfunction, patients with myocardial infarction who have persisted for more than 12 months (IIbA) may be considered, and new evidence of PEGASUS/DAPT;
combined with high ischemia risk factors (age ≥65 years old, diabetes requiring drug treatment, two myocardial infarction history, multiple coronary lesions or chronic insufficiency) may be considered. If DAPT can tolerate no bleeding wells, ticagrelor 60mg Bid combined with spirin can be used for 12 months (IIbB), (new evidence: PEGASUS) .
Summary:
The main significance of updating DAPT guidelines at home and abroad to Chinese clinical practice:
. Both ESC guidelines recommend using a scoring system to guide the course of DAPT. However, prediction and scoring systems based on Chinese populations (such as OPT-CAD scores, etc.) still need to undergo large-scale verification;
. ESC2018 Revascularization Guidelines propose a step-down strategy. uses DAPT strategies that are suitable for disease development, which may enable patients to obtain better clinical net benefits. However, the methods of lowering the treatment need to be discussed, such as dual anti-anti- or multi-anti-mono-anti-anti-anti-mono-anti-anti-effect, strong → warm-effect, shortening the course of treatment ( has evidence of ILOVEIT2 in China) , lowering the dose, etc.;
3. For patients with ACS: ① All three guidelines recommend: ticagrelor when applying DAPT for the first time; ② ESC 2018 Revascularization Guidelines for the first time: If patients with PCI have not used P2Y12 receptor inhibitors in the past, they can consider using GPI
4. For patients with SCAD: ① All three guidelines recommend 6 months of DAPT after PCI.ESC2018 Revascularization Guidelines recommend that DAPT treatment course be reduced to 1 (IIbC) to 3 (IIaA) months for those with high risk of bleeding (2016 China PC Guidelines are recommended to be <6>
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