Optimizing the risk and benefit ratio of dual

antiplatelet in ACS patient

Erwinanto MD

Department of Cardiology and Vascular Medicine

Division of Cardiovascular, Department of Internal Medicine

Faculty of Medicine Universitas Padjadjaran/Hasan Sadikin Hospital

Bandung
General Approach to the Management of

DAPT in Acute Coronary syndrome

 PROBABLE

Hamm CW, et al. Eur Heart J doi:10.1093/eurheartj/ehr236

 Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min) Immediate ED general treatment

• Vital sign
• Oxygen saturation
• Obtain IV access
• Obtain ECG 12 lead
• Brief history and physical exam
• Check contraindication for fibrinolytic
• Initial serum cardiac markers
• Initial electrolyte and coagulation
study
• Portable chest x-ray ( 30 minutes)
• O2 at 4 L/min (maintain O2 sat 90%)
• Aspirin 160-325 mg
• Nitroglycerin SL, spray, or IV
• Morphine IV 2-4 mg repeated every
5-10 minutes (if pain not relieved
with nitroglycerine)
Memory: “MONA” greets all patients

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 PROBABLE

DEFINITE PROBABLE

Hamm CW, et al. Eur Heart J doi:10.1093/eurheartj/ehr236

 STEMI NSTEACS

Primary PCI Fibrinolytic Ischemic guided Early invasive

Initiate dual anti-platelet and anticoagulant therapy

Initiate secondary prevention therapy

Post hospital care

• Continue dual antiplatelet

• Continue secondary prevention

 Antiplatelet loading and maintenance dose

• Aspirin oral loading dose 162-325 mg and maintenance dose 81-

162 mg long-term

• In patients treated with DAPT, a daily aspirin dose of 81 mg

(range, 75 mg to 100 mg) is recommended

Clopidogrel 300-600 mg loading dose follows by 75 mg daily

Ticagrelor 180 mg loading dose follows by 90 mg daily.

 P2Y12 inhibitors

Roffi M, et al. Eur Heart J 2015. doi:10.1093/eurheartj/ehv320

 Acute coronary syndromes

Medical Lytic (STEMI) PCI CABG

therapy (BMS or DES)

Class I Class I Class I Class I

At least 12 mo Minimum 14 days At least 12 mo Resume DAPT
(clopidogrel, and idealy at least (clopidogrel, to complete 12
ticagrelor) 12 mo ticagrelor, mo
(clopidogrel) prasugrel)

No high risk of bleeding and no significant overt

bleeding on DAPT

˃12 mo may be reasonable (class IIb)

Levine GN, et al. JACC 2016;68:1082–115
DAPT Score

Levine GN, et al. JACC 2016;68:1082–115

 Levine GN, et al.
JACC 2016;68:1082–115
Do not discontinue DAPT unless

mandatory
 Effects of aspirin withdrawal (n= 1236)

Mean delay between aspirin withdrawal and ACS 10±1.9 days

50 P=0.001
% of STEMI in patients who

3
39 2.6
40

new coronary events

% of patients with
relapsed

30 2
1.5
20 18
1
10

0 0
Yes No STEMI NSTEMI

Aspirin withdrawal Coronary events

Ferrari e et al JACC 2005;45:456-9

 Mortality after MI among those who continued and
discontinued thienopyridine therapy at 1 month after MI

15
Discontinued
Continued
Mortality (%)

10

p<0.001

0
0 1 2 3 4 5 6 7 8 9 10 11 12

Months
Spertus JA, et al. Circulation. 2006;113:2803-2809
If interruption of DAPT becomes mandatory because of

urgent high-risk surgery (e.g. neurosurgery) or in the

case of a major bleed that cannot be controlled by local

treatment, no alternative therapy can be proposed as a

substitute to DAPT to prevent stent thrombosis.

Platelet function test
 Platelet Function Test

Trenk D, et al. J Am Coll Cardiol 2012;59:2159–64

ARCTIC Study

Collet JP, et al. N Engl J Med 2012;367:2100-9.

To date, no RCT has demonstrated that routine platelet

function testing or genetic testing to guide P2Y12

inhibitor therapy improves outcome; thus, the routine

use of platelet function and genetic testing is not

recommended (Class III: No Benefit)

Levine GN, et al. JACC 2016;68:1082–115

Proton pump inhibitors and

DAPT
The European Medicines Agency (EMA) and the US
Food and Drug Administration (FDA) have issued
warnings about diminished clopidogrel action when
combined with proton pump inhibitors, especially
omeprazole and esomeprazole, which reduce
metabolic activation of clopidogrel. Pharmacodynamic
studies, but not clinical outcome studies, support the
use of newer proton pump inhibitors such as
pantoprazole instead of omeprazole in order to avoid
this negative drug–drug interaction.
Take-home messages
• Initiate DAPT to all patients with ACS unless
contraindicated

• Do not discontinue DAPT in patients with ACS unless

mandatory

• Shorter duration of DAPT in patients with high bleeding

risk

• Routine use of platelet function test is not recommended

• Pantoprazole, instead of omeprazole, is required for

patients on DAPT who have a history or at high risk of GI
bleeding