POST STENTING DUAL ANTIPLATELET THERAPY DURATION J BAUCUM MD FACC CAROLINA CARDIOLOGY GHS

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1 POST STENTING DUAL ANTIPLATELET THERAPY DURATION J BAUCUM MD FACC CAROLINA CARDIOLOGY GHS

2 Post Stenting Dual Antiplatelet Therapy When can I stop it? Intracoronary stenting is a frequent intervention for acute myocardial infarction, unstable angina, and chronic angina/myocardial ischemia which limits quality of life

3 Dual antiplatelet therapy, aspirin and thienopyridines, is utilized to reduce risks of acute, sub acute, and delayed stent thrombosis. Duration guidelines/recommendations are dependent on type of stent and clinical setting Duration is independent of which antiplatelet medication is prescribed Aspirin, typically 81 mg po q day, is recommended long term

4 IN GENERAL, DRUG-ELUTING STENTS HAVE REDUCED RISKS OF INSTENT RESTENOSIS RELATIVE TO BARE METAL STENTS TYPICALLY, DRUG-ELUTING STENTS HAVE DELAYED ENDOTHELIAZATION OF THE STENT STRUTS RESULTING IN INCREASED RISK OF THROMBOSIS

5 CLINICAL SETTINGS MYOCARDIAL INFARCTION: STEMI AND NSTEMI DURATION OF DUAL ANTIPLATELET THERAPY IS RECOMMENDED FOR A MINIMUM OF ONE YEAR FOR BOTH DRUG-ELUTING STENTS AND BARE METAL STENTS

6 SPECIAL CIRCUMSTANCES LEFT MAIN STENTING TYPICALLY LIFETIME/LONGTERM FOR DRUG- ELUTING AND BARE METAL STENTS HISTORY OF STENT THROMBOSIS TYPICALLY LIFETIME/LONG TERM FOR DRUG-ELUTING AND BARE METAL STENTS

7 SPECIAL CIRCUMSTANCES SAPHENOUS VEIN GRAFTS WITH PREVIOUS THROMBOSIS, EXTENSIVE STENTING, AND IF MARKED GRAFT/NATIVE VESSEL SIZE MISMATCH TYPICALLY LONG TERM DUAL ANTIPLATELET THERAPY

8 SPECIAL CIRCUMSTANCES TECHNICALLY COMPLEX INTERVENTIONS SUCH AS EXTENSIVE VESSEL STENTING, COMPLEX BIFURCATION INTERVENTION, CHRONIC TOTAL OCCLUSIONS, RESIDUAL DIFFUSE NATIVE OR GRAFT DISEASE MAY HAVE LONGER DURATION OF THERAPY

9 FAQ s: DUAL ANTIPLATELT SPECIAL CIRCUMSTANCES CYPER STENTS, A SIROLIMUS ELUTING STENT WHICH MAY REQUIRE LONGER TIME PRIOR TO STRUT ENDOTHELIAZATION

10 IS ANTIPLATELET THERAPY INTERRUPTION SAFELY POSSIBLE PRIOR TO THE MINIMUM DURATION RECOMMENDATIONS? YES, PREFERRABLY FOR MAJOR BLEEDING PROBLEMS/RISKS OR URGENT/EMERGENT SURGERIES/PROCEDURES

11 IF ELECTIVE DUAL ANTIPLATELET THERAPY INTERRUPTION IS NECESSARY TRY TO CONTINUE ASPIRIN THERAPY WITHOUT INTERRUPTION STOP THE DRUG FOLLOWED WITHIN 2-3 DAYS BY ADMISSION FOR INTRAVENOUS ANTIPLATELET THERAPY, eg AGGRASTAT OR HEPARIN, ADMINISTRATION UNTIL WITHIN HOURS OF THE PROCEDURE WITH RESTARTING POST-OP UNTIL PO DRUG MAY BE RESTARTED/LOADED.

12 WITH INCREASING FREQUENCY SOME DENTAL/ORAL SURGERY, OPHTHALMOLOGIC, DIAGNOSTIC ENDOSCOPIC, AND OTHER PROCEDURES ARE BEING SAFELY PERFORMED WITHOUT INTERRUPTION OF ANTIPLATELET THERAPY

13 THE ART OF DUAL ANTIPLATELET THERAPY DURATION INCORPORATES THE GUIDELINES AND RECOMMENDATIONS ALONG WITH ANY SPECIAL CIRCUMSTANCES, CONSIDERATION OF SETTINGS IN WHICH BLEEDING RISKS OUTWEIGH BENEFITS OF CONTINUED THERAPY ALONG WITH PATEINT PREFERENCES.

14 THE FUTURE GOAL OF MINIMIZING RESTENOSIS OCCURRENCE WHILE LIMITING RISKS OF STENT THROMBOSIS AND SYSTEMIC BLEEDING RISKS NEW GENERATION STENTS BIOABSORBABLE STENTS BIOABSORBABLE POLYMER STENTS

15 CLINICAL SETTINGS UNSTABLE ANGINA and CHRONIC ANGINA/ISCHEMIA DRUG-ELUTING STENTS: MINIMUM OF ONE YEAR BARE METAL STENTS: MINIMUM OF ONE MONTH

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