March 29, 2016, American College of Cardiology -- The American College of Cardiology and the American Heart Association today released updated guidelines for dual antiplatelet therapy in patients with coronary artery disease.

Dual antiplatelet therapy refers to the combination of aspirin with a second aspirin-like but stronger drug referred to as a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor). Dual antiplatelet therapy is used to reduce the risks of future heart attack and coronary stent thrombosis (in which a stent is occluded by a blood clot). These new guideline recommendations are based on the findings of recent studies of the length of time patients with coronary artery disease, specifically those with myocardial infarction (heart attack) and those undergoing coronary stent implantation, should be treated with dual antiplatelet therapy. The new recommendations are also based on current use of coronary stents that have a lower risk of clotting off than some older stents.

The document updates recommendations on duration of dual antiplatelet therapy across six previously published guidelines: the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention (PCI), the 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, the 2013 ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, the 2014 ACC/AHA Guideline for Non-ST-Elevation Acute Coronary Syndromes and the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.

Studies examining shorter duration (three to six months) of dual antiplatelet therapy compared with a standard 12 months of therapy in select, generally lower-risk patients did not find any increased risk of stent thrombosis and, in some cases, found less bleeding. Other studies of prolonged or extended dual antiplatelet therapy for an additional 18 or 36 months found a decrease in the risk of heart attack and stent thrombosis at the expense of an increase in bleeding risk.

“Treatment with more intensive antiplatelet therapy and treatment for a longer duration of time with antiplatelet medicines in general involves a fundamental tradeoff between a decreased risk of future heart attack and an increased risk of bleeding complications,” said Glenn N. Levine, MD, FAHA, FACC professor of medicine at Baylor College of Medicine and director of the Cardiac Care Unit at the Michael E. DeBakey VA Medical Center in Houston and the chair of the writing committee for the document.

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