Anesthesiology and Intensive Care

The American College of Cardiology (ACC) and the American Heart Association (AHA)  issued updated guidelines for dual antiplatelet therapy in patients with coronary artery disease (CAD).  Dual antiplatelet therapy is a combination of aspirin with a P2Y12 inhibitor such as clopidogrel, prasugrel or ticagrelor. This therapy is prescribed to reduce the risks of future heart attack and coronary stent thrombosis. This focused update accounts for 12 new studies on the optimal duration of dual antiplatelet therapy (DAPT) after coronary stenting, particularly later-generation drug-eluting stents (DES). The update affects parts of prior guidelines on percutaneous coronary intervention, coronary artery bypass grafting, stable ischemic heart disease (IHD), ST-segment elevation myocardial infarction (STEMI), non-ST-segment acute coronary syndromes (NSTEACS), and perioperative evaluation for noncardiac surgery. The class (strength) of recommendations is noted below in pertinent...

Because aspirin dosing recommendations across ACC/AHA clinical practice guidelines are not consistent with regard to dose or class of recommendation, and because aspirin is a component of DAPT(Dual antiplatelet therapy), a comprehensive review of these issues was undertaken. Large overviews, including studies of nearly 200,000 persons, have consistently shown that lower aspirin doses (≤100 mg daily) are associated with less major and total bleeding than are higher doses, either when used as monotherapy or when combined with the P2Y12 inhibitor clopidogrel . Daily aspirin doses as low as 30 mg to 50 mg inactivate the platelet cyclo-oxygenase-1 enzyme and inhibit thromboxane production. Studies comparing lower (75 mg to 150 mg) with higher aspirin doses have consistently found comparable ischemic event rates with either dose when used as monotherapy or when combined with the P2Y12 inhibitor clopidogrel. The efficacy of ticagrelor seems to be decreased in patients treated with...