What are the clinical indications for Dual Antiplatelet Therapy (DAPT) in patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) who have undergone Percutaneous Coronary Intervention (PCI) with stent placement?

From the Guidelines

Dual antiplatelet therapy (DAPT) is strongly recommended for all patients with non-ST-elevation myocardial infarction (NSTEMI) who have undergone percutaneous coronary intervention (PCI) with stent placement, with a standard regimen consisting of aspirin 81mg daily indefinitely plus a P2Y12 inhibitor for a minimum of 12 months after PCI, as supported by the most recent guidelines 1. The choice of P2Y12 inhibitor should be individualized, with ticagrelor and prasugrel providing more potent platelet inhibition than clopidogrel and preferred in higher-risk patients without contraindications. Key considerations for DAPT duration include:

• A minimum of 12 months for patients with ACS treated with PCI, unless there are contraindications such as excessive risk of bleeding 1
• Shorter DAPT duration of 6 months may be considered for patients at high bleeding risk
• Extended DAPT beyond 12 months may be beneficial for patients with high ischemic risk and low bleeding risk Regular assessment of bleeding risk is essential throughout the DAPT course, and patients should be educated about the importance of medication adherence and the risks of premature discontinuation. The most recent guidelines from the European Heart Journal in 2021 1 provide the strongest evidence for these recommendations, superseding earlier guidelines from 2016 1 and 2011 1.

From the FDA Drug Label

Prasugrel tablets are a P2Y12 platelet inhibitor indicated for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients with acute coronary syndrome who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) (1.1). Patients with ST-elevation myocardial infarction (STEMI) when managed with either primary or delayed PCI (1.1).

The clinical indication for DAPT (Dual Antiplatelet Therapy) in patients with NSTEMI (Non-ST-Elevation Myocardial Infarction) who have undergone PCI (Percutaneous Coronary Intervention) with stent placement is to reduce the risk of thrombotic cardiovascular events, including stent thrombosis.

• The recommended dosage is a single 60 mg oral loading dose, followed by 10 mg once daily, in combination with aspirin (75 mg to 325 mg) daily 2.
• In patients weighing less than 60 kg, consider lowering the maintenance dose to 5 mg once daily to minimize the risk of bleeding 2.
• It is essential to note that prasugrel should not be discontinued prematurely, as this increases the risk of stent thrombosis, myocardial infarction, and death 2.

From the Research

Clinical Indications for DAPT in Patients with NSTEMI who have Undergone PCI with Stent Placement

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care for patients with NSTEMI who have undergone PCI with stent placement, as it reduces the risk of stent thrombosis and subsequent cardiovascular events 3.
• The duration of DAPT is typically 12 months after PCI, unless the patient is at high risk for bleeding 3.
• In patients with acute coronary syndromes, prasugrel and ticagrelor may be preferred over clopidogrel due to their more potent antiplatelet effect, but they are also associated with a higher bleeding risk 3, 4.
• The timing of PCI in patients with NSTEMI is also important, with early invasive treatment associated with lower risk of ischemic outcomes 5.
• After DAPT discontinuation, P2Y12 inhibitor monotherapy may be a viable option, as it has been shown to reduce major bleeding by 50-60% compared to DAPT without a significant increase in ischemic outcomes 6, 7.
• A network meta-analysis found that P2Y12 inhibitor monotherapy was associated with a significantly lower risk of myocardial infarction and similar risk of major bleeding compared to aspirin monotherapy 7.

Key Considerations

• Aspirin should be continued indefinitely at a low dose (75-100 mg daily) 3.
• Noncardiac surgery should be delayed until 12 months after coronary stenting if possible 3.
• Patients receiving coronary stents who require warfarin are at high risk for bleeding if they also receive DAPT, and omission of aspirin may be advantageous in such patients 3.