Clinical consensus statements for ACS managed by PCI (without baseline indications for OAC)
| Single antithrombotic therapy |
| Compared with 12-month DAPT, aspirin withdrawal after 1-to-3-month DAPT and continuation with P2Y12 inhibitor in the form of:• ticagrelor monotherapy provides net benefit with reduced bleeding complications without increased risk of non-fatal or fatal ischaemic events;• prasugrel monotherapy has not been investigated and cannot, therefore, be supported;• clopidogrel monotherapy is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25).a |
| Compared with ≥12-month DAPT, P2Y12 inhibitor withdrawal after 3- or 6-month DAPT and continuation of aspirin is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25). |
| Dual antithrombotic therapy |
| During the first year after PCI in ACS, DAPT with a newer P2Y12 inhibitor (prasugrel or ticagrelor) is superior to DAPT with clopidogrel in terms of ischaemic outcomes and is therefore warranted. |
| Long-term DAPT, instead of P2Y12 inhibitor monotherapy, remains justifiable in patients at high risk of recurrent ischaemic eventsb in whom the bleeding risk does not pose concerns. |
| One-month DAPT duration is warranted in HBR patients (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 2583).c |
| The combination of rivaroxaban 2.5 mg b.i.d. and a P2Y12 inhibitor cannot be supported as a routine strategy without additional investigation. |
| The combination of rivaroxaban 2.5 mg b.i.d. with clopidogrel or ticagrelor may be justifiable following PCI in aspirin-intolerant patients who are not HBR. |
| Triple antithrombotic therapy |
| Triple antithrombotic therapy with rivaroxaban 2.5 mg b.i.d. in combination with aspirin and clopidogrel remains a therapeutic option in selected patients at high risk of thrombotic complications and low risk of bleeding.d |
| Single antithrombotic therapy |
| Compared with 12-month DAPT, aspirin withdrawal after 1-to-3-month DAPT and continuation with P2Y12 inhibitor in the form of:• ticagrelor monotherapy provides net benefit with reduced bleeding complications without increased risk of non-fatal or fatal ischaemic events;• prasugrel monotherapy has not been investigated and cannot, therefore, be supported;• clopidogrel monotherapy is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25).a |
| Compared with ≥12-month DAPT, P2Y12 inhibitor withdrawal after 3- or 6-month DAPT and continuation of aspirin is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25). |
| Dual antithrombotic therapy |
| During the first year after PCI in ACS, DAPT with a newer P2Y12 inhibitor (prasugrel or ticagrelor) is superior to DAPT with clopidogrel in terms of ischaemic outcomes and is therefore warranted. |
| Long-term DAPT, instead of P2Y12 inhibitor monotherapy, remains justifiable in patients at high risk of recurrent ischaemic eventsb in whom the bleeding risk does not pose concerns. |
| One-month DAPT duration is warranted in HBR patients (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 2583).c |
| The combination of rivaroxaban 2.5 mg b.i.d. and a P2Y12 inhibitor cannot be supported as a routine strategy without additional investigation. |
| The combination of rivaroxaban 2.5 mg b.i.d. with clopidogrel or ticagrelor may be justifiable following PCI in aspirin-intolerant patients who are not HBR. |
| Triple antithrombotic therapy |
| Triple antithrombotic therapy with rivaroxaban 2.5 mg b.i.d. in combination with aspirin and clopidogrel remains a therapeutic option in selected patients at high risk of thrombotic complications and low risk of bleeding.d |
ACS, acute coronary syndrome; ARC, Academic Research Consortium; b.i.d., bis in die; DAPT, dual antiplatelet therapy; HBR, high bleeding risk; MI, myocardial infarction; OAC, oral anticoagulation; PADs, peripheral arterial diseases; PCI, percutaneous coronary intervention.
aThis evidence was generated in patients who underwent durable polymer everolimus-eluting stent implantation; consequently, these results may not extend to patients who receive other stent types.
bHigh ischaemic risk is defined as diffuse multivessel coronary artery disease with at least one of the following: diabetes mellitus requiring medication, recurrent MI, peripheral arteria disease, or chronic kidney disease with estimated glomerular filtration rate 15–59 mL/min/1.73 m2.
cThis evidence was generated in patients who underwent biodegradable polymer sirolimus-eluting stent implantation; consequently, these results may not extend to patients who receive other stent types.
dSuch as patients in whom the use of ticagrelor and prasugrel is not an option, those with recurrent ischaemic events on prior use of ticagrelor or prasugrel in whom adherence to these drugs has been established, or patients in whom the early transition towards dual therapy with aspirin and rivaroxaban is envisioned.
Clinical consensus statements for ACS managed by PCI (without baseline indications for OAC)
| Single antithrombotic therapy |
| Compared with 12-month DAPT, aspirin withdrawal after 1-to-3-month DAPT and continuation with P2Y12 inhibitor in the form of:• ticagrelor monotherapy provides net benefit with reduced bleeding complications without increased risk of non-fatal or fatal ischaemic events;• prasugrel monotherapy has not been investigated and cannot, therefore, be supported;• clopidogrel monotherapy is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25).a |
| Compared with ≥12-month DAPT, P2Y12 inhibitor withdrawal after 3- or 6-month DAPT and continuation of aspirin is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25). |
| Dual antithrombotic therapy |
| During the first year after PCI in ACS, DAPT with a newer P2Y12 inhibitor (prasugrel or ticagrelor) is superior to DAPT with clopidogrel in terms of ischaemic outcomes and is therefore warranted. |
| Long-term DAPT, instead of P2Y12 inhibitor monotherapy, remains justifiable in patients at high risk of recurrent ischaemic eventsb in whom the bleeding risk does not pose concerns. |
| One-month DAPT duration is warranted in HBR patients (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 2583).c |
| The combination of rivaroxaban 2.5 mg b.i.d. and a P2Y12 inhibitor cannot be supported as a routine strategy without additional investigation. |
| The combination of rivaroxaban 2.5 mg b.i.d. with clopidogrel or ticagrelor may be justifiable following PCI in aspirin-intolerant patients who are not HBR. |
| Triple antithrombotic therapy |
| Triple antithrombotic therapy with rivaroxaban 2.5 mg b.i.d. in combination with aspirin and clopidogrel remains a therapeutic option in selected patients at high risk of thrombotic complications and low risk of bleeding.d |
| Single antithrombotic therapy |
| Compared with 12-month DAPT, aspirin withdrawal after 1-to-3-month DAPT and continuation with P2Y12 inhibitor in the form of:• ticagrelor monotherapy provides net benefit with reduced bleeding complications without increased risk of non-fatal or fatal ischaemic events;• prasugrel monotherapy has not been investigated and cannot, therefore, be supported;• clopidogrel monotherapy is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25).a |
| Compared with ≥12-month DAPT, P2Y12 inhibitor withdrawal after 3- or 6-month DAPT and continuation of aspirin is associated with greater MI risk among patients who were not selected for being at HBR (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 25). |
| Dual antithrombotic therapy |
| During the first year after PCI in ACS, DAPT with a newer P2Y12 inhibitor (prasugrel or ticagrelor) is superior to DAPT with clopidogrel in terms of ischaemic outcomes and is therefore warranted. |
| Long-term DAPT, instead of P2Y12 inhibitor monotherapy, remains justifiable in patients at high risk of recurrent ischaemic eventsb in whom the bleeding risk does not pose concerns. |
| One-month DAPT duration is warranted in HBR patients (e.g. based on ARC-HBR criteria or PRECISE-DAPT ≥ 2583).c |
| The combination of rivaroxaban 2.5 mg b.i.d. and a P2Y12 inhibitor cannot be supported as a routine strategy without additional investigation. |
| The combination of rivaroxaban 2.5 mg b.i.d. with clopidogrel or ticagrelor may be justifiable following PCI in aspirin-intolerant patients who are not HBR. |
| Triple antithrombotic therapy |
| Triple antithrombotic therapy with rivaroxaban 2.5 mg b.i.d. in combination with aspirin and clopidogrel remains a therapeutic option in selected patients at high risk of thrombotic complications and low risk of bleeding.d |
ACS, acute coronary syndrome; ARC, Academic Research Consortium; b.i.d., bis in die; DAPT, dual antiplatelet therapy; HBR, high bleeding risk; MI, myocardial infarction; OAC, oral anticoagulation; PADs, peripheral arterial diseases; PCI, percutaneous coronary intervention.
aThis evidence was generated in patients who underwent durable polymer everolimus-eluting stent implantation; consequently, these results may not extend to patients who receive other stent types.
bHigh ischaemic risk is defined as diffuse multivessel coronary artery disease with at least one of the following: diabetes mellitus requiring medication, recurrent MI, peripheral arteria disease, or chronic kidney disease with estimated glomerular filtration rate 15–59 mL/min/1.73 m2.
cThis evidence was generated in patients who underwent biodegradable polymer sirolimus-eluting stent implantation; consequently, these results may not extend to patients who receive other stent types.
dSuch as patients in whom the use of ticagrelor and prasugrel is not an option, those with recurrent ischaemic events on prior use of ticagrelor or prasugrel in whom adherence to these drugs has been established, or patients in whom the early transition towards dual therapy with aspirin and rivaroxaban is envisioned.
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