In a patient with chronic stable angina without recent coronary revascularization, is there a role for dual antiplatelet therapy?

DAPT in Stable Angina Without Recent Revascularization

There is no role for dual antiplatelet therapy (DAPT) in patients with chronic stable angina who have not undergone recent coronary revascularization—single antiplatelet therapy is the standard of care. 1

Primary Recommendation

• Single antiplatelet therapy with either aspirin (75-325 mg daily) or clopidogrel (75 mg daily) is the appropriate treatment for stable angina without recent revascularization. 1
• The European Society of Cardiology explicitly states that patients with stable coronary artery disease have a Class I indication for DAPT only if percutaneous revascularization has been performed. 1
• There is no evidence supporting DAPT in patients with stable CAD treated conservatively (medically managed without intervention). 1

Evidence Against DAPT in This Population

• The benefit of dual antiplatelet therapy in symptomatic peripheral artery disease (a similar atherosclerotic condition) without recent revascularization is uncertain, with increased bleeding risk offsetting potential ischemic benefits. 1
• Clinical trials demonstrate that DAPT in stable disease populations increases major bleeding risk without clear mortality or morbidity benefit when revascularization has not been recently performed. 1
• Extended DAPT beyond 12 months does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. 2

When DAPT IS Indicated in Stable Angina

DAPT becomes appropriate only in these specific scenarios:

• After percutaneous coronary intervention (PCI) with stent placement: minimum 6 months for drug-eluting stents in stable disease. 3
• Within 12 months of acute coronary syndrome, regardless of whether revascularization was performed. 4
• During the 1-6 month period following elective PCI, with aspirin plus a P2Y12 inhibitor. 3

Critical Pitfall to Avoid

• Do not continue or initiate DAPT based solely on symptom severity (angina frequency) in the absence of recent revascularization or acute coronary syndrome. 1
• A case example from the European Heart Journal illustrates this error: an 82-year-old woman with stable angina was inappropriately maintained on aspirin plus clopidogrel for 8 years after refusing CABG, leading to recurrent epistaxis requiring multiple interventions. 1
• The bleeding complications from inappropriate DAPT use directly impair quality of life and can precipitate anemia requiring transfusion. 1

Optimal Single Antiplatelet Selection

• Clopidogrel 75 mg daily demonstrated superior efficacy compared to aspirin for prevention of major adverse cardiovascular events in the CAPRIE trial, with similar bleeding rates. 1
• Aspirin 75-100 mg daily remains an acceptable alternative if clopidogrel is contraindicated or not tolerated. 1
• Ticagrelor showed equivalent efficacy to clopidogrel in stable PAD but with higher adverse event rates, making it less favorable for chronic stable disease. 1

Alternative Strategy for High-Risk Stable CAD

• Low-dose rivaroxaban 2.5 mg twice daily plus aspirin is an evidence-based option for patients with stable atherosclerotic disease at high ischemic risk, though it increases major bleeding risk. 1
• This combination from the COMPASS trial reduced major adverse cardiovascular events and major adverse limb events in symptomatic atherosclerotic disease. 1
• This strategy should be reserved for patients without high bleeding risk, history of hemorrhagic stroke, or severe kidney disease. 1