JAMA Review Tackles Intricacies of Medical Therapy After PCI

The particulars of medical therapy following percutaneous coronary intervention (PCI) with stenting are just as important for general practitioners to understand as interventional cardiologists, asserts a review of post-PCI medical management published in the July 10, 2013, issue of the Journal of the American Medical Association.

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the cornerstone of such management, note Emmanouil S. Brilakis, MD, PhD, of the University of Texas Southwestern Medical Center (Dallas, TX), and colleagues. The paper summarizes current guidelines and published literature regarding the ideal duration of DAPT, the role of newer antiplatelets, and special considerations like concomitant medications and individualized therapy.

Dr. Brilakis told TCTMD that the aim of the paper is to describe the “current status of the field” rather than provide new data.

“This [represents] the way we’re practicing right now, or how most people are practicing,” he said in a telephone interview. “Interventionalists are obviously familiar with this. [The review] was addressed mainly to non-interventionalists and non-cardiologists . . . because many people out there take care of patients with stents who then get surgery or have other diseases, and there’s a little bit of confusion about what happens, how long to give dual antiplatelet therapy, and how to do it.”

DAPT Usually Required for 12 Months

Among the familiar advice is the stipulation that a P2Y12 inhibitor, typically clopidogrel, should be administered for 12 months after PCI unless contraindicated by high bleeding risk. For ACS patients in particular, prasugrel and ticagrelor stand to reduce ischemic events but are associated with increased bleeding. Aspirin, ideally at a low dose of 75 to 100 mg daily, should be continued indefinitely, the paper notes.

However, the authors also point out that the ideal DAPT duration is a moving target. Zotarolimus- and everolimus-eluting stents, approved in Europe, are to be followed by 1 and 3 months of DAPT, respectively. “Availability of fully bioresorbable stents or stents with bioresorbable polymer may allow further reduction in DAPT duration,” they write. “Careful patient selection and counseling on the importance of DAPT can minimize the risks associated with early DAPT discontinuation.”

Special considerations outlined in the review include the need for noncardiac surgery, which Dr. Brilakis and colleagues advise should be delayed until 12 months after stenting if possible. As for concomitant medications, proton pump inhibitors (PPIs) should be given when patients on DAPT are at high risk for GI bleeding, they note, adding that because of concerns over omeprazole interfering with clopidogrel metabolism and perhaps affecting outcome, other PPIs may be preferable.

Medical therapy in patients who require oral anticoagulation is another issue that “people are still very confused about,” Dr. Brilakis observed.

The randomized WOEST study, presented at the 2012 European Society of Cardiology Congress in Munich, Germany, last fall and subsequently published in the Lancet, “is a single trial and not huge but it’s the best thing that we have,” he said. Its results suggest that such patients may fare better by eliminating aspirin and instead should receive clopidogrel and oral anticoagulation alone.

The review also takes on the controversy surrounding the use of genetic and functional testing to individualize DAPT. “Given the significant interindividual variability in the degree of platelet inhibition achieved with clopidogrel, tailoring of antiplatelet therapy according to functional platelet activity is theoretically an appealing strategy,” the physicians note, citing the 2010 ‘black box’ warning by the US Food and Drug administration suggesting that cytochrome 2C19 genetic testing could be helpful. Functional testing, they add, has failed to improve clinical outcomes in 2 large clinical trials.

Physician Education a Worthwhile Pursuit

In an interview with TCTMD, Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), said that knowledge, or the lack thereof, about post-PCI medical therapy among non-interventionalists is “absolutely” a concern, especially considering that less than 25% of patients in the United States are seen regularly by a cardiologist. Reviews such as this could be helpful, he agreed, but noted that “there are so many attempts already to educate primary physicians in particular and also general cardiologists. This is not the first.”

But what is particularly useful here, Dr. Brener added, is the review’s table summarizing both US and European guidelines.

Eric R. Bates, MD, of the University of Michigan Medical Center (Ann Arbor, MI), characterized the paper in an e-mail communication as “a nice review of the cardiovascular literature for internal medicine [that] mimics the guideline recommendations [and provides] no new controversies or information.”

One other way “to decrease bleeding risk that is often forgotten is the avoidance of NSAIDs” while on multiple antiplatelet drugs, he added.

According to Dr. Brener, the only area to not receive enough emphasis in the review is the growing body of evidence supporting shorter therapy durations. “The rate of stent thrombosis with newer stents is very, very low and that will be a significant change. Because ultimately, if the guidelines were changed to 3 months [of DAPT], then noncompliance will be reduced dramatically, even if we do nothing, statistically speaking,” he commented.

However, Dr. Brener emphasized, stent thrombosis is a “serious issue, so caution is appropriate. . . . I don’t expect [the guidelines to change] in the next year.”

 

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Source:
Brilakis ES, Patel VG, Banerjee S. Medical management after coronary stent implantation: A review. JAMA. 2013;310:189-198.

 

 

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