2017 ESC Focused Update on Dual Antiplatelet Therapy in Coronary Artery Disease developed in collaboration with the EACTS* @eEsc *: European Association for Cardio-Thoracic Surgery European Society of Cardiology2017 ESC Focused Update on Dual Antiplatelet @ ier in Coronary Artery Disease developed ESC in collaboration with EACTS ie) The Task Force for the Management of Dual Antiplatelet Therapy in Coronary Artery Disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS) ESC Chairperson: Marco Valgimigli (Switzerland). Authors/Task Force Members: Héctor Bueno (Spain), Robert Byrne (Germany), Jean-Philippe Collet (France), Francesco Costa (Italy), Anders Jeppsson (Sweden), Peter Juni (Canada), Adnan Kastrati (Germany), Philippe Kolh (Belgium), Laura Mauri (USA), Gilles Montalescot (France), Franz-Josef Neumann (Germany), Mate Petricevic (Croatia), Marco Roffi (Switzerland), Philippe Gabriel Steg (France), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain). Additional Contributor: Glenn Levine (USA). wuweseardio.org/auidelines Focused Update on DAPT in Coronary Artery art Journal 2017 doi:10.1093/aurhaart 2, davalopad in collaboration with EACTS. 2Classes of recommendations @eEsc European Society Per ESC UEC Ty ‘of Cardiology SRC ud corn Class Il Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of the given treatment or procedure. Class ta Weight of evidence/opinion im favaurof | Shouldbe usefulness efficacy. considered, Classilb ——_-Usefulness/efficacy is less well established by May be conside evidence/opinion. SeneemeS IRL seed ua Psa ers aE AE direst ber inend Pa) ostafeunast ameLevel of evidence @eEsc European Society of Cartclogy 4 Data derived from multiple randomized clinical DRT) Tle RiP) OMe bee] fac 4 Data derived from a single randomized clinical trial Level of evidence B . ‘anole = Canon chtonirctea es “wa wescardio.org/guidelines +2017 ESC Focused Update on DAPT in Coronary Artery Disease, cevelopad in collaboration with EACTS: ‘urepenr Heart Journal 2017 - do:20,1093/aurhearti/ahx"19)What is new in the 2017 ESC focussed update on DAPT? @EsC. ‘of Carcolagy ‘Change in recommendations, /New recommendations 2017 New/tevised concepts ‘Metall stent and DAPT duration Switeh betwen PY, tore isk scores to Buide DAPT ration “PRECISE DAET sore ~pAeT score Speci pong ~Definicn of como PI Unfaourabe pref OAC ard 4° ‘Sender considerations and ‘pec! populations DDAPT dutation without stenting “Model nanagement “(AiG or eatiesugery ‘nteoapuaion and DAP “feuieand cri ettng ~Desing regimen @ Gn Bo an waweseardlo.org/guldelines 2017 ESC Focuses Uplate on DAPT in Coronary artary Disease, cavalopes in collaboration with EACTS, 5 (Guropann Heart ournal 2017~ dalst01093/eurhaart/ai<19)Investigated DAPI Duration History of dual antiplatelet therapy (DAPT) in patients @ ESC with coronary artery disease aotsseye [ASPIRIN | CLOPIDOGREL nae tm Sociol |e | aa ne FANTASTIC: - RMT See 5 ont at ag s wise ume —|—6- cui ee \ ‘amc f 1 ANTART havc QD ome? 8 = 1 “s (14, OPTIOUAL some -OHARIGUA REALLATE } 1 Goer ¥ 014) 2316) 1996 2017 Size of the circles denotes sample size @ &® @ () kos Perimeter of the circles denotes type of investigated population Mixed clinical presentation at the time of =» DAPT initiated in patients with prior stent implantation myocardia infarction 1 ~ DAPT for primary prevention 5 ~ Acute coronary syndrome at presentai speen Hee our 057 -do 3109/eheifehat)Risk scores validated for dual antiplatelet therapy duration decision-making Time of use Atthe time oF coronary stenting ‘After'12 months of uneventful DAPT @Esc DAPT duration strategles assessed Short DAPT (3-6 months) vs. Standard/long DAFT (12-24 months) Standard DAPT (12 months) vs Long DAPT (30 months) Score calculation’ Score range HB Betis IY 105 <10 WBC <5 8 0121416 18 20 Age = $60_80_ 700 aso ca 0) 0 Por Mo Yen Bleeding Score 0.24 6 8 10i214ie 80200262829 Points Tere errr Tie TOO points Age 215 2p 65 t0<75 apt <65 Opt arate smoking +1pt Diabetes mellitus opt Milat presentation +1pt Prior PC or prior MI +t PaclitaxeL-eluting stent +1 pt Stentdiameter <3 mm +1 pt CHF or LVEF <30% +2pt Vein graft stent +20t “Tie 10 points Decision making cut-off suggested ‘Score 225 Short DAPT. Score <25 ~ Standard/long DAPT ‘Score 32 = Long DAPT Score <2— Standard DAPT Calculator ‘worw pracizedap tscore.com worn daptstudy.org uu eseardio.org/guidelinas 2047 ESC Foeur Update on DAPT in Coronary Art Disease, davalopad in collaboration with EACTS. (Curopean Heart ourna 2027 dli20.1092/eurheart/2twe19) European Society of CardolagyUse of risk scores as guidance for the @esc duration of dual antiplatelet therapy ESC of cardiology Recommendations Class | Level The use of risk scores designed to evaluate the benefits and risks of different DAPT durations may be considered. ww w.eteardio.org/guidelnes 2047 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS, 8 (European Heart Journal 2047 di:40.1083/urhaart/ain“49)P2Y,, inhibitor selection and timing @eEsc European Society ‘of Cardiology Recommendations In patients with ACS, ticagrelor (180 mg loading dose, 90 mg twice daily) on top of aspirin is recommended, regardless of initial treatment strategy, including patients pre-treated with clopidogrel (which should be discontinued when ticagre lor is commenced) unless there are contra-indications. In patients with ACS undergoing PCI, prasugrel (60 mg loading dose, 10 mg daily dose) on top of aspirin is recommended for P2Y,, inhibitor-naive patients with NSTE-ACS or initially conservatively managed STEMI if indication for PCI is established, or in STEMI patients undergoing immediate coronary catheterization unless there is a high-risk of life- threatening bleeding or other contra-indications. wuweseardio.org/gudelines Update on DAFT in Coronary Artery Disease, cevalapad in collaboration with EACTS 8 Jounal 2017 doi30.1093/aurhaarti/ahw18)P2Y,, inhibitor selection and timing @esc (continued) European Seciety of Calogy Recommendations Pre-treatment with a P2Y,, inhibitor is generally recommended in patients in whom coronary anatomy is known and the decision to proceed to PCI is made as well as in patients with STEMI. In patients with NSTE-ACS undergoing invasive management, ticagrelor administration (180 mg loading dose, 90 mg twice daily), or clopidogrel (600 mg loading dose, 75 mg daily dose) if ticagrelor is not an option, should be considered as soon as the diagnosis is established. In patients with stable CAD pre-treatment with clopidogrel may be considered if the probability of PCI is high. incolaboration witheacts 10 dale on DAFT in Coronary Artery Disease, cevalopae wa weseardio.org/gudelines our esc earl ournal 2047 do i40.4099/eurhearti/ahasi9) urs paaP2Y,, inhibitor selection and timing @esc (continued) Eppa Sct logy Recommendations Class Clopidogrel (600 mg loading dose, 75 mg daily dose) on top of aspirin is recommended in stable CAD patients undergoing coronary stent implantation and in ACS patients who cannot. receive ticagrelor or prasugrel, including those with prior intracranial bleeding or indication for OAC. Clopidogrel (300 mg loading dose in patients <75, 75 mg daily dose) is recommended on top of aspirin in STEMI patients receiving thrombolysis. wuwceseardio.org/gudelinas 2047 ESC Fee fue date on DAPT in Corenary Arty Disen nal 2017 - de :40.4093/eurheart/el collaboration with EAEP2Y,, inhibitor selection and timing : @Esc (continued) European Society of Carsaogy Recommendations Class Ticagrelor or prasugrel on top of aspirin may be considered instead of clopidogrel in stable CAD patients undergoing PCI, taking into account the ischaemic (e.g. high SYNTAX score, prior stent thrombosis, location and number of implanted stents) and bleeding (e.g. according to PRECISE-DAPT) risks. In NSTE-ACS patients in whom coronary anatomy is not known, it is not recommended to administer prasugrel. wu weseardio.org/guideines 2017 ES€ Focused Update on DART in Coronary Artery Disease, davaloped in collaboration with EACTS 2 (Europaat Heart sourna 2017~ dol:40.1093/eurhearf/aixe19)Measures to minimize bleeding while on dual antiplatelet therapy © Be as oan Recommendations Class | Level Radial over femoral access is recommended for coronary angiography and PCI if performed by an expert radial operator. In patients treated with DAPT, a daily aspirin dose of 75-100 mg is recommended. APPI in combination with DAPT is recommended. Routine platelet function testing to adjust antiplatelet therapy before or after elective stenting is not recommended. wa weseardio.org/gudelines our esc (Cur pean a Upuiate on DAFT in Coronary Artary Disease, developed incollaboration with FACTS 13 Journal 2017~ deit0.1092/2urheati/2hnst9)Switching between oral P2Y,, inhibitors @ Recommendations In patients with ACS who were previously exposed to clopidogrel, switching from clopidogrel to ticagrelor is recommended early after hospital admission at a loading dose of 180 mg irrespective of timing and loading dose of clopidogrel, unless contra-indications to ticagrelor exist. Additional switching between oral P2Y,, inhibitors may be considered in cases of side effects/drug intolerance according to the proposed algorithms. wa wescardio.ore/auidelines lope in olaborat ESC European Society ‘of Cardiology uAlgorithm for switching between oral P2Y,, inhibitors @ in the acute setting ESC Society CLOPIDOGREL of Cardiology Ticagrelor LD (180 mg) 2ah after last Prasugrel dose / PRASUGREL /' / TICAGRELOR / Prasugrel LD (60 mg) \\, 24h after last Ticagrelor dose wuwceseardio.org/gudelinas 2047 ESC Foeusad Update on DART in Coronary tary Disease, developed in collaboration with EACTS, 15 (European Heart Journal 2017- di:40.1093/eurhenrt/2in“10)Algorithm for switching between oral P2Y,, inhibitors in @ SC the chronic setting ESC = CLOPIDOGREL of Cardiolosy CHRONIC SETTING Ticagrelor MD [90 mg b.id.) 24h after last Clopidogrel dose PRASUGREL J _/ TICAGRELOR / Prasugrel LD (60 mg) | \\ 24h after last Ticagrelor dose wa weseardio.org/gudelines Focused Update on DART in Gororary Feartlourna t017~ del30.2093/aur 4, developed in collaboration with EACTS, 16Dual antiplatelet therapy duration and related stent © ESC choices in patients with stable coronary artery disease so.m secs treated with percutaneous coronary intervention ie) Class | Level Recommendations In patients with stable CAD treated with coronary stent implantation, DAPT consisting of clopidogrel in addition to aspirin is generally recommended for 6 months, irrespective of the stent type. Irrespective of the intended DAPT duration, DES is the preferred treatment option. In patients with stable CAD considered at high bleeding risk (e.g. PRECISE-DAPT 225), DAPT for 3 months should be considered*. In patients with stable CAD treated with drug-coated balloon, DAPT for 6 months should be considered. “ihe evidence rupporing the Tecommer dain Gomes Tom lwo studios where loiarolimus elaahg Endeavour sia stent has been investigated i conjunction with a 3-month DAPT regimen, sease, developed in collaboration with EACTS, ww w.eteardio.org/guidelnes 2047 £S¢ Focused Update on DART in Govorary Arter a9) (Europaat Heart ourna 2017~ del:40.1093/eurheaDual antiplatelet therapy duration and related stent choices in patients with stable coronary artery disease treated with percutaneous coronary intervention (continued) Recommend In patients with stable CAD treated with bioresorbable vascular scaffolds, DAPT for at least 12 months should be considered. In patients with stable CAD who have tolerated DAPT without a bleeding complication and who are at low bleeding but high thrombotic risk, continuation of DAPT with clopidogrel for >6 months and <30 months may be considered. In patients with stable CAD in whom 3-month DAPT poses safety concerns, DAPT for 1 month may be considered*. “month DAPT ater implantation of zetralimus-citing Endeavour apn tent or dru coated stent reduced risk of relncevertion, myocardial infarction and incon stentl cf ston thrombosis compared to bare metal stent undor similar DAPT duration. [ts unclear if this evidence applies to other contemporary DES. wo wescardio.ore/auidelines 2017 ESC European Society Cardiology FyDual antiplatelet therapy duration in patients @ with acute coronary syndrome treated with ESC percutaneous coronary intervention pe) Recommendations In patients with ACS treated with coronary stent implantation, DAPT with a P2Y,, inhibitor on top of aspirin is recommended for 12 months unless there are contra-indications such as excessive risk of bleeding (e.g. PRECISE-DAPT >25). In patients with ACS and stent implantation who are at high- risk of bleeding (e.g. PRECISE-DAPT 225), discontinuation of P2Y,, inhibitor therapy after 6 months should be considered. In patients with ACS treated with bioresorbable vascular scaffolds, DAPT for at least 12 months should be considered. wuusesearalo.org/gulelinas Coronary Artary Disease, savalopes|inealatoration withencis 19 1093 /2urheart me)Dual antiplatelet therapy duration in patients @ with acute coronary syndrome treated with ESC percutaneous coronary intervention (continued) = °°” Recommendations In patients with ACS who have tolerated DAPT without a bleeding complication, continuation of DAPT for longer than 12 months may be considered. In patients with MI and high ischaemic risk who have tolerated DAPT without a bleeding complication, ticagrelor 60 mg b.i.d. for longer than 12 months on top of aspirin may be preferred over clopidogrel or prasugrel. sease, developed incollaboration with EacTs 20 wa weseardio.org/gudelines 7 na9)Algorithm for dual antiplatelet therapy (DAPT) —rinu @ ESC ga in patients treated with wale pe (of Cardiology percutaneous coronary aT | a intervention quan Goma [Benen Econo [E-rauge fi} nagerr 2017 ESC Focused Update on DART in Coronary Artery Disease, cavalopac in collaboration with ECTS 2% ‘European Heart Journal 2017 - do:20,1093/aurhearti/2haai9) waweseardlo.org/guldelinesAlgorithm for dual antiplatelet therapy (DAPT) in patients treated with percutaneous coronary intervention ESC European Society of carology rae eee ma lel) Treatment indication eg DES/8MS or DCB ES DES/BMS or DCB No Yes Time ale] Imo, -..|. -1| was.enardio.org/euidelnes 2047 ESC Focused Update on DAFT in Coronary Artry Disease, devalpad in collaboration with EACTS 72 (European Heart ourna 2017- doi:10.2093/aurhaarti/abnat8)Algorithm for dual antiplatelet therapy (DAPT) in patients @ treated with percutaneous coronary intervention ESC European Society of Carlology 3mo. -.-}. mo. - 12mo. | Tass 15 Al 90 mo Aen NM al al tl al A fale)’. Continue DAPT >12 mo. In pts with prior MI (Class ib & [A] Aspirin [El] =Clopidogrel [RR] =Prasugrel Fl] = Ticagretor wuw.escardio.or/zuidelines 2017 FSC Focuses Uplate on BAPT in Coronary Artary Dicaate, savalopes|incolabortion with ERCTS 23 (Eure paan Heart Journal 2017 dol:10.1083/eurhear}/aiw239)Dual antiplatelet therapy in patients treated @esc with cardiac surgery with stable or unstable Bisa Seay coronary artery disease Recommendations It is recommended that the Heart Team estimates the individual bleeding and ischaemic risks and guide the timing of CABG as well as the antithrombotic management. In patients on aspirin who need to undergo non-emergent cardiac surgery, itis recommended to continue aspirin at a low daily regimen throughout the peri-operative period. In patients treated with DAPT after coronary stent implantation who subsequently undergo cardiac surgery, it is recommended to resume P2Y,, inhibitor therapy postoperatively as soon as deemed safe so that DAPT continues until the recommended duration of therapy is completed. wa wescardio.ore/auidelines 2017 ESC Focused Update on DAFT in Coronary Artery Disease, cavalope! in collaboration with FACTS (urepaa” Haart Journal 2017 do:40,4093/aurharti/ahas®) ‘of Cardiology a"Dual antiplatelet therapy in patients treated with cardiac surgery with stable or unstable coronary artery disease (continued) ‘of Cardiology Recommendations In patients with ACS (NSTE-ACS or STEMI) treated with DAPT and undergoing CABG and not requiring long-term OAC therapy, resumption of P2Y,, inhibitor therapy as soon as deemed safe after surgery and continuation up to 12 months is recommended In patients on P2Y,, inhibitors who need to undergo non-emergent cardiac surgery, postponing surgery for at least 3 days after discontinuation of ticagrelor, at least 5 days after clopidogrel, and at least 7 days after prasugrel should be considered. In CABG patients with prior MI who are at high-risk of severe bleeding (e.g. PRECISE-DAPT 225), discontinuation of P2Y,, inhibitor therapy after 6 months should be considered. wuwceseardio.org/gudelinas 2017 ESC Forusad Update on DAFT in Coronary Artery Diseas (European Heart ourna 2017- doisd0.093/eurhear}/atn ped ineollaboration with EACTS, 3Dual antiplatelet therapy in patients treated ) with cardiac surgery with stable or unstable ESC coronary artery disease (continued) ao Recommendations Class | Level Platelet function testing may be considered to guide decisions on timing of cardiac surgery in patients who have recently received P2Y,, inhibitors, In patients perceived at high ischaemic risk with prior MI and CABG who have tolerated DAPT without a bleeding complication, treatment with DAPT for longer than 12 and up to 36 months may be considered. wuwceseardio.org/gudelinas 2017 ESC Foeused Update on DAFT in Cererary Artery Disease; davalopad in ellaboration with EACTS ‘European Heart Journal 2047 - dor40,1093/authearti/ahx"19)eT a RSLs Te Leu Algorithm for dual CFU ce EARS Let antiplatelet therapy (DAPT) in patients ee with acute coronary tenere syndrome undergoing coronary artery bypass grafting ame. |. 3mo. +. smo, +. ‘Time from amo. + 30mo. + wa weseardio.org/gudelines 2017 ESC Foe urs paa Update on DAT in Coronary Artery Disease, 19.092 /eurhea @Esc European Society ‘of Cardiology Treatments presented within the sare line are “orted in alphabetic ‘order, no preferential recommendation nls dea sted saloped incollaboration with tacts 27Algorithm for dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome undergoing @Esc coronary artery bypass grafting swcaalony Patients Acute Coronary Syndrome year aeolian as) ECR eA) 4 Aspirin C3 Clopidogrel Time from ‘treatment initiation Imo. -|- Hy stesrrar Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated otherwise. wuweseardio.org/gudelines 2047 ESC Foe zy ure Update on DART in Gororary Artery Disease, devalopad in collaboration with EACTS fourna 2037 eis40.1083/aurhaart}/ain“49)Algorithm for dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome undergoing coronary artery | @ESC bypass grafting (continued) scar ints with Acute Coronary Syndrome Undergoi Peet eae Aen) Time from spirin ‘treatment initiation clopidogrel 6 mo. |. rasugrel icagrelor 22 mo. x Treatments presented within the same line are sorted in alphabetic order, no preferential recommendation unless clearly stated (Class ib B otherwise. su weseardio.org/avidh 2017 ESC Foeused Update on DAFT in Cererary Artery Disease, davaloped in collaboration with EACTS 2 (European Heart Journal 2017- di:40.1093/eurhenrt/2in“10)Dual antiplatelet therapy duration in patients @ with acute coronary syndrome undergoing ESC medical therapy management a eetoaty Recommendations Class | Level In patients with ACS who are managed with medical therapy alone and treated with DAPT, it is recommended to continue P2Y,, inhibitor therapy (either ticagrelor or clopidogrel) for 12 months. Ticagrelor is recommended over clopidogrel, unless the bleeding risk outweighs the potential ischaemic benefit. In patients with medically managed ACS who are at high-risk of bleeding (e.g. PRECISE-DAPT 225), DAPT for at least 1 month should be considered. ww.eteardio.org/guidelnes 2017 £S¢ Focused Update on DART in Coronary Artery Disease, developed incollaboration with FACTS 30 (Europaat Heart ourna 2017~ dol:10.1093/aurhearf/aha19)Dual antiplatelet therapy duration in patients @ with acute coronary syndrome undergoing ESC medical therapy management (continued) a Recommendations In patients with prior Ml at high ischaemic risk who are managed with medical therapy alone and have tolerated DAPT without a bleeding complication, treatment with DAPT in the form of ticagrelor 60 mg b.i.d. on top of aspirin for longer than 12 months and up to 36 months may be considered, In patients with prior MI not treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not eligible for treatment with ticagrelor, continuation of clopidogrel on top of aspirin for longer than 12 months may be considered. Prasugrel is not recommended in medically managed ACS patients. wu weseardio.org/guideines 2017 ES€ Focused Update on DAFT in Coronary Artery Disease, cavaloped in collaboration withERCTS 32 (Europaat Heart sourna 2017~ dol:40.1093/eurhearf/aixe19)Prorat orun tas ca Algorithm for dual Undergoing Medical Treatment Alone antiplatelet therapy @ ESC Society (DAPT) in patients with of Cardiology acute coronary syndrome undergoing medical management a - [El =cendeze! [B= tessier Treatments presented within the sare line are sorted in alphabetic . order, no preferential Fecommencation unless clearly stated otherwise. wth rir Na (Coss 6 wu weseardio.org/guideines 2047 £S¢ Focused Update on DART in Covorary Artery Disease, developed incollaboration with FACTS 32 (€uropean Kear sournal 2017 dol:10.1033/eurheary/atnanAlgorithm for dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome undergoing @esc medical management reaaloyy ith Acute Coronary Syndrome Undergoing Medical Treatment Alone No Yes [A] = Aspirin [Eh -copiogret [Bj -Teeerelor Treatments presented within the same line are Time from ‘treatment initiation 1mo. | - 3mo. |. sorted in alphabetic order, no preferential Gino. ») RE 826s uated recommendation unless clearly stated otherwise. oration with acs 32 savalopas 2017 FS¢ Foeusad Update on DAPI in Caronary artary wuweseardio.org/euitelines (European Heart ourna 2017- do\:10.1093/ourhearAlgorithm for dual antiplatelet therapy (DAPT) in patients ath acute coronary syndrome undergoing medical ESC management (continue ooreogy ieni enn iris Se bed ea) Time from treatment initiation [A)=Asonin [= copidogret [= eau ‘Treatments presented within the same line are 30mo. -|-| sorted in alphabetic order, no preferential pier recommendation ‘with prior Mi unless clearly stated (Class Ib B otherwise. wawscardioore/evdelnes 2017 tse Fo Update on DAFT in Coronary Artery Disease, cavaloped in collaboration with acts 34 (Guropaan Heart ourna 2017 dals30.1093/aurhaary/atwea9)Strategies to avoid bleeding complications in ) patients treated with oral anticoagulant ESC ‘of Cardiology Assess ischaemic and bleeding risks using validated risk predictors (e.g. CHA,DS_- VASc, ABC, HAS-BLED) with a focus on modifiable risk factors. Keep triple therapy duration as short as possible; dual therapy after PCI (oral anticoagulant and clopidogrel) to be considered instead of triple therapy. Consider the use of NOACs instead of VKA when NOACs are not contra-indicated. Consider a target INR in the lower part of the recommended target range and maximize time in therapeutic range (i.e. >65-70%) when VKA is used. Consider the lower NOAC regimen tested in approval studies and apply other NOAC regimens based on drug-specific criteria for drug accumulation. Clopidogrel is the P2Y,, inhibitor of choice. Use low-dose ($100 mg daily) aspirin. * Routine use of Pls. wuweseardio.org/euitelines 2047 ESC Faeusas Update on DAPY in Coronary Artary Di (European Heart sourna 2017- dol:10.1083/aurheart}/amxa13) avalopas incollaborstion with RCTS 35High-risk features of stent-driven recurrent @ ischaemic events EO ce ‘of Cardiology + Prior stent thrombosis on adequate antiplatelet therapy. * Stenting of the last remaining patent coronary artery. + Diffuse multivessel disease especially in diabetic patients. * Chronic kidney disease (i.e. creatinine clearance <60 mL/min). + Atleast three stents implanted. * Atleast three lesions treated, + Bifurcation with two stents implanted. * Total stent length >60 mm. * Treatment of a chronic total occlusion. www esearao.ore/eudelinas 2017 ESC Faeusas Update on DAPI in Coramary Arty Dicat (Guropean Keart ournal 2017 do|:10.1053 eurheati/ahaa ‘avalopas ncollaborstion with kaCIS 36Unfavourable patient profile for a combination of oral anticoagulant and antiplatelet therapy @Esc European Society ‘of Cardiology + Short life expectancy. Ongoing malignancy. Poor expected adherence. Poor mental status. End stage renal failure. Advanced age. Prior major bleeding/prior haemorrhagic stroke Chronic alcohol abuse. Anaemia. * Clinically significant bleeding on dual antithrombotic therapy wuusesearalo.org/gulelinas 2047 ESC Focuses Update on DAVY in Corona ArtaryDisaae, (European Heart ournal 2017- dolit0.1093/eurhearti/=h@19) 1o¢ collaboration with Excrs 37Dual antiplatelet therapy duration in patients with indication for oral anticoagulation Recommendations Itis recommended to administer periprocedurally aspirin and clopidogrel in patients undergoing coronary stent implantation. In patients treated with coronary stent implantation, triple therapy with aspirin, clopidogrel! and OAC should be considered for 1 month, irrespective of the type of stent used. Triple therapy with aspirin, clopidogrel and OAC for longer than 1 month and up to 6 months should be considered in patients with high ischaemic risk due to ACS or other anatomical/ procedural characteristics, which outweigh the bleeding risk. Dual therapy with clopidogrel 75 mg/day and OAC should be considered as an alternative to 1-month triple antithrombotic therapy in patients in whom the bleeding risk outweighs the ischaemic risk. ol 19.2093/aurhaaral wa wescardio.ore/auideines 18) , developed in colaboralon with EAGTS. @esc European Society ‘of Cardiology 2Dual antiplatelet therapy duration in patients with indication for oral anticoagulation @esc (continued) of Cariclogy Recommendations Class | Level Discontinuation of antiplatelet treatment in patients treated with OAC should be considered at 12 months. In patients with an indication for VKA in combination with aspirin and/or clopidogrel, the dose intensity of VKA should be carefully regulated with a target INR in the lower part of the recommended target range anda time in the therapeutic range >65-70%. When a NOACis used in combination with aspirin and/or clopidogrel, the lowest approved dose effective for stroke prevention tested in AFib trials should be considered. When rivaroxaban is used in combination with aspirin and/ or clopidogrel, rivaroxaban 15 mg q.d. may be used instead of rivaroxaban 20 mg qd. The use of ticagrelor or prasugrel is not recommended as part of triple antithrombotic therapy with aspirin and OAC. wu weseardio.org/guideines 2017 ESC Focused Update on DAFT in Coronary Artery Disease, avaloped in collaboration withEACTS 39 (Europaat Heart sourna 2017~ dol:40.1093/eurhearf/aixe19)Algorithm for dual antiplatelet therapy Conces about “ue @ ESC (DAPT) in patients eo agen oteariloyy with an indication HOT cat oral anticoagulation — treatment undergoing initiation percutaneous 1mo. coronary A = Aeskin intervention (PCI) 30, fun Bl =Cetogrel = Orlarticagulstion mo... Beyond TW oacalone mo. wa weseardio.org/gudelines Update on DART in Govorary Artery Diseas nal 2017 ~ do i40.4099/eurhear liad incollaboration witheacts 0Algorithm for dual antiplatelet therapy (DAPT) in @ ESC patients with an indication for oral anticoagulation Eee Undergoing percutaneous coronary intervention (PCI) stanly ECR Ome F icoagulation undergoing PCI Time from treatment - = == initiation [Act] {A[c a 1 mo. Triple Therapy Sauce |) erty) imo. } Ecce Pes Gore wuw.enardo.org/euilnes 2047 ESC Focuses Update on DAPY in Coronary Arar Dizeas,savaloped in collaboration with ACTS ‘Gurepenn Heart Journal 2047 - do:20,1093/eurheart/ahx"19)Algorithm for dual antiplatelet therapy (DAPT) in @ patients with an indication for oral anticoagulation undergoing ESC percutaneous coronary intervention (PCI) (continued) European Society ‘of Cardiology 3 mo. - wich H(A Ray a Dual Therapy - Pee mo. : Ceare ie) A Yo Drs ears 12mo. ... Beyond ‘Class a B 12mo. = aspirin [E] = Clopidogrel [GJ = Oral anticoagulation wu weseardio.org/guideines 2017 ES€ Focused Update on DAFT in Coronary Artery Disease, davaloped in collaboration with EACTS {Euro paar Heart Journal 2017 de:20.1093faurheartiahxai9) >Dual antiplatelet therapy in patients @esc undergoing elective non-cardiac surgery Spar cesat ‘of Cardiology Recommendations It is recommended to continue aspirin perioperatively if the bleeding risk allows, and to resume the recommended antiplatelet therapy as soon as possible post-operatively. After coronary stent implantation, elective surgery requiring discontinuation of the P2Y,, inhibitor should be considered after 1 month, irrespective of the stent type, if aspirin can be maintained throughout the peri-operative period. Discontinuation of P2Y,, inhibitors should be considered at least 3 days before surgery for ticagrelor, at least 5 days for clopidogrel and at least 7 days for prasugrel. A multidisciplinary expert team should be considered for pre-operative evaluation of patients with an indication for DAPT before elective surgery. wuwceseardio.org/gudelinas 2017 incollazoration with EACTS 49 date on DAPT in Corenary Artary Disease, e art Jeurnal 2047 - do :40.4093/2urhearti/2hx419)Dual antiplatelet therapy in patients @esc undergoing elective non-cardiac surgery igen a ‘of Cardiology (continued) Recommendations In patients with recent MI or other high ischaemic risk features requiring DAPT, elective surgery may be postponed for up 6 to months. If both oral antiplatelet agents have to be discontinued perioperatively, a bridging strategy with intravenous antiplatelet agents may be considered, especially if surgery has to be performed within 1 month after stent implantation. It is not recommended to discontinue DAPT within the first month of treatment in patients undergoing elective non cardiac surgery. in collaboration with EACTS rwweseardio.org/guidelnes 2017 es Update on DART in Gororary Artery Disease, devalopad (Curspaan earl sowrna 2017~ dsist0.093/eurheart/ahaaI9) aTiming for elective non-cardiac surgery in patients treated with dual antiplatelet therapy (DAPT) after percutaneous @eEsc coronary intervention (PCI) ot coialoyy P2Y,, inhibitor interruption after PCI for elective non-cardiac surgery Time from DAPT initiation 6mo. -| wa weseardio.org/guidelines 2047 ESC Focused Update on DART in Coronary Artery Disease, developed incollaboration with FACTS 45 (€uropean Beart sournal 2017 dol:10.1033/aurheart/2inais)Minimal discontinuation and re-implementation time frames of dual antiplatelet therapy (DAPT) for patients @ ESC European Society undergoing elective surgery of Carclogy Se ‘) Tene Bears eae recy ‘ASPIRIN? i. 1-4 Minimal delay for P2V,, interruption Daysafter surgery Expected average platelet function recovery + Decision to stop aspirin throughout surgery should be made on a single case basis taking into account the surgical bleeding risk. 7 Inpatients not requiring OAC. sof collaboration with Eacrs 46 wus esearalo.org/gulelinas 2047 ESC Fi ateon European Heart ourna 2017- a arti/2inal9) 19.093/eurnearti/atGender considerations and those for special @esc populations European Society ‘of Cardiology Recommendations Similar type and duration of DAPT are recommended in male and female patients. Itis recommended to reassess the type, dose and duration of DAPT in patients with actionable bleeding complication while on treatment. Similar type and duration of DAPT should be considered in patients with and without diabetes mellitus. Prolonged (i.e. >12 months) DAPT duration should be considered in patients with prior stent thrombosis, especially in the absence of correctable causes (e.g. lack of adherence or correctable mechanical stent-related issues). wa weseardio.org/gudelines Update on DART in Coronary Artery Disea nal 2017 ~ do i40.4099/eurhear liad in collaboration with EACTS ”Gender considerations and those for special Populations (continued) © Be as enor Recommendations Class | Level Prolonged (i.e. >12 months) DAPT duration may be considered in CAD patients with LEAD. Prolonged (i.e. >6 months) DAPT duration may be considered in patients who underwent complex PCI. wa weseardio.org/gudelines 2017 ESC Foe urs paa e dale on DAFT in Coronary Artery’ sease, levalopae!incollatoration withtacrs 8 al 2017 do 40.4099/eurhearti/2haa9)Piece eae @esc ocnees as + Continue DAPT. TRIVIAL BLEEDING Any bleeding not requiring medical intervention or further evaluation wuation or skip one single next pill. + Reassure the patient. eg. skin bruising or ecchimosis, + Identify and discuss with the patient possible preventive self-resolving epistaxis, minimal peites conjunctival bleeding + Counsel patient on the importance of drug-adherence. Legend DAPT management OAC management | General recommendations ‘wuts oglgudetner 317 FoxucdUpssanr DET noraray nary wae seigesin laanratar arth EATS [uapea Hea lol 3017-61033 /ourmarjebas)CSS rt ne ue CE cas uc) Sea Ve @eEsc European Seciety MILD BLEEDING Any bleeding that requires medical attention without requiring hospitalization e.g. not self resolving epistaxis, moderate conjunctival bleeding, genitourinary or upper/lower gastrointestinal bleeding without significant blood loss, mild haemoptysis Legend DAPT management OAC management General recommendations of Cartclogy + Continue DAPT. + Consider shortening DAPT duration or switching to less potent P2Y, » inhibitor (ie.from ticagrelor/ prasugrel to clopidogrel), especially if recurrent bleeding occurs. + Incase of triple therapy consider downgrading to dual therapy, preferably with clopidogrel and OAC. + Identify and possibly treat concomitant conditions associated with bleeding (e.g. peptic ulcer, haemorrhoidal plexus, neoplasm). + Add PPI if not previously implemented. * Counsel patient on the importance of drug-adherence. 50 wesartece/gudeines 21796 ocasa Updaeon DET crarary Aner Osea oevtgesin alaoratar eh EATS cvapear Hea” Jour 201T-ob 0.033 /ureanyee9)ne eed ee eet @esc croranseath e.g. genitourinary, respiratory or upper/lower gastro- intestinal bleeding with significant blood loss or requiring transfusion Legend DAPT management OAC management General recommendations ‘of carsology ‘+ SAPT, preferably with the P2Y,. inhibitor especially in case of upper GI bleeding. * Reinitiate DAPT as soon as deemed safe. * Consider shortening DAPT duration or switching to less potent P2Y.2, especially ifrecurrence occurs. |* Consider OAC dis. or reversal until bleeding is controlled, unless very high thrombotic risk * Reinitiate treatment within one weekif dinically indicated. For VKA target INR of 2.0-2.5 unless overriding indication (i.e. mechanical heart valves or cardiac assist device) for NOAC consider the lowest effective dose. * In case of triple therapy consider downgrading to dual therapy, preferably with clopidogrel and OAC. * Ifpatients on dual therapy, consider stopping antiplatelet Tx. + Consider. PPI if Glbbleeding occurred. + Identify and possibly treat concomitant conditions assodated bleeding (e.g. peptic ulcer, haemorrhoidal plexus, neoplasm). + Counsel patient on the importance of drug-adherence, ‘wut aucoglgudetnes 317 oxucdUpssanr DEPT nororary 3a Uae seigesin clanortar veh EATS (urapea Hea lol 2017-6 1033 /urmarjebe9)h dual antiplatelet therapy + OAC @ Esc European Society of carilogy + Consider stopping DAPT and continue with SAPT, preferably with the P2 inhibitor ‘especially in case of upper Gi bleeding. + Mfbleading persists despite tweatment or reatment is not possible, constder stopping all antithrombotic medications + Once bleedinghas ceased, re-evaluate the need for DAPT or SAPT, preferably with the P2Yq inhibitor especially in case of upper Gl bleeding. + IDAPT is re-started, consider shortening DAPT duration or switching to lesspotent P2Y,, inhibitor (Le. from eagrelor/prasugrel to cloptdogrel),espectally If recurrent bleeding occurs. Bleeding during treatment e.g. severe genitourinary, * Consider stopping and reversing OAC until bleeding s controlled unless prohibitive respiratory thromboticris ie. mechanical heart valve in mitral position, cardiac assist device or upper/lower anise inner aul) ane'ereeies [swe walerailcoivien ie aarsnalse gastrointestinal bleeding consider a targetINR of 2.0-2.5 unless overiding indication (e, mechanical heart valves or cardiac assist device) for NOAC consider the lowest effective dose, Teseaal + ifpatient on tiple therapy consider downgrading to dual therapy with clopidogrel and OAC. if patients on dual therapy, conskler stopping antiplatelet therapy if deemed DAPT management safe. + Consider iv, PPLif GI bleeding occurred ren eeemen + RBC transfusion f HB<7-8 g/Dl. 5 + Consider platelet transfusion, See ere eee + Urgent surgical or endoscopic treatment ofbleeding source if deemed possible... 52 rape far 3057- a 0.1098 /urarijebe)Bleeding during treatment with dual antiplatelet therapy + OAC @ ESC European Society e.g. massive overt genitourinary, respiratory or upper/lower gastrointestinal bleeding, active intracranial, spinal or intraocular haemorrhage, or any bleeding causing haemodynamic instability. Legend DAPT management ‘OAC management General recommendations of carilogy *Immediately discontinue all antithrombotic medications. Once bleeding has ceased, re-evaluate the need for DAPT or SAPT, preferably with the P2Y,, inhibitor especially in case of upper Gl bleeding. * Stop and reverse OAC. * Fluid replacement if hypotension. * Consider RBC transfusion irrespective of HB values. + Platelet transfusion. * Consider iv. PPI if GI bleeding occurred. * Urgent surgical or endoscopic treatment of bleeding source if deemed possible. 33 8.08European Society ‘of Cardiology www.escardio.org/quidelines Full Text Addenda Clinical Cases ESC Pocket Guidelines App and much more... 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