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Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology

Barillà, Francesco; Pelliccia, Francesco; Borzi, Mauro; Camici, Paolo; Cas, Livio Dei; Di Biase, Matteo; Indolfi, Ciro; Mercuro, Giuseppe; Montemurro, Vincenzo; Padeletti, Luigi; Filardi, Pasquale Perrone; Vizza, Carmine D.; Romeo, Francescoon behalf of the 2015–2016 Board of the Italian Society of Cardiology

Journal of Cardiovascular Medicine: January 2017 - Volume 18 - Issue 1 - p 1–9
doi: 10.2459/JCM.0000000000000434

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.

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

Correspondence to Francesco Pelliccia, MD, PhD, Department ‘Attilio Reale’, Sapienza University, Via del Policlinico 155, 00161 Rome, Italy Tel: +39 0348 3392006; fax: +39 06 330 62516; e-mail:

Received 14 May, 2016

Revised 8 August, 2016

Accepted 18 August, 2016

© 2017 Italian Federation of Cardiology. All rights reserved.