title: Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology.
abstract: Definition of the optimal duration of dual anti-platelet therapy (DAPT) is an important clinical issue, given the large number of patients having percutaneous coronary intervention (PCI), the costs and risks of pharmacologic therapy, the consequences of stent thrombosis, and the potential benefits of DAPT in preventing ischaemic outcomes beyond stent thrombosis. Nowadays, the rationale for a prolonged duration of DAPT should be not only the prevention of stent thrombosis, but also the prevention of ischaemic events unrelated to the coronary stenosis treated with index PCI. A higher predisposition to athero-thrombosis may persist for years after an acute myocardial infarction, and even stable patients with a history of prior myocardial infarction are at high risk for major adverse cardiovascular events. Recently, results of pre-specified post-hoc analyses of randomized clinical trials, including the PEGASUS-TIMI 54 trial, have shed light on strategies of DAPT in various clinical situations, and should impact the next rounds of international guidelines, and also routine practice. Accordingly, the 2015 to 2016 the Board of the Italian Society of Cardiology addressed newer recommendations on duration of DAPT based on most recent scientific information. The document states that physicians should decide duration of DAPT on an individual basis, taking into account ischaemic and bleeding risks of any given patient. Indeed, current controversy surrounding optimal duration of DAPT clearly reflects the fact that, nowadays, a one size fits all strategy cannot be reliably applied to patients treated with PCI. Indeed, patients usually have factors for both increased ischaemic and bleeding risks that must be carefully evaluated to assess the benefit/risk ratio of prolonged DAPT. Personalized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk/benefit to the patient according to changes in his/her clinical profile. Also, in order to derive more benefit than harm from new treatments, a multi-parametric approach using several risk scores of the ischaemic and bleeding risks might improve the process of risk factor characterization. In patients with high ischaemic risk, particularly those with a history of myocardial infarction, the benefits of extended DAPT (particularly with ticagrelor up to 3 years) are likely to outweigh the risks.
authors.affiliation: aDepartment of Cardiovascular Sciences, Sapienza University bDepartment of Cardiovascular Disease, Tor Vergata University of Rome, Rome cCardiothoracic and Vascular Department, Vita-Salute University, Milan dDepartment of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia eDepartment of Medical & Surgical Sciences, University of Foggia, Foggia fDivision of Cardiology, Department of Medical and Surgical Sciences, 'Magna Graecia' University, Catanzaro gDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari hHeart and Vessels Department, University of Florence, Florence iDepartment of Advanced Biomedical Sciences, Federico II University, Naples, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Barillà
authors.forename: Francesco
authors.initials: F
authors.lastname: Pelliccia
authors.forename: Mauro
authors.initials: M
authors.lastname: Borzi
authors.forename: Paolo
authors.initials: P
authors.lastname: Camici
authors.forename: Livio Dei
authors.initials: LD
authors.lastname: Cas
authors.forename: Matteo
authors.initials: M
authors.lastname: Di Biase
authors.forename: Ciro
authors.initials: C
authors.lastname: Indolfi
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Mercuro
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Montemurro
authors.forename: Luigi
authors.initials: L
authors.lastname: Padeletti
authors.forename: Pasquale Perrone
authors.initials: PP
authors.lastname: Filardi
authors.forename: Carmine D
authors.initials: CD
authors.lastname: Vizza
authors.forename: Francesco
authors.initials: F
authors.lastname: Romeo
mesh_terms: D000241:Adenosine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D002309:Cardiology / Q000592:standards*; D004334:Drug Administration Schedule; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007558:Italy; D009203:Myocardial Infarction / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D012955:Societies, Medical; D013927:Thrombosis / Q000209:etiology / Q000517:prevention & control*; D000077486:Ticagrelor
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077486:Ticagrelor; D000241:Adenosine; D001241:Aspirin