MAIN PROVISIONS OF DUAL ANTIPLATELET THERAPY AND CURRENT TRENDS IN ITS CHANGE. LECTURE

This article provides a small excursion into the history of dual antiplatelet therapy (DAT) as well as main points of modern approaches to its use. Based on completed randomized clinical trials it also makes an assumption about how approaches to DAT can change in the future. DAT as a combination of acetylsalicylic acid (ASA) and one of the P2Y12 receptor inhibitors (clopidogrel, prasugrel or ticagrelor) has been used in clinical practice for almost 20 years, its use is mainly recommended at the earliest stage of acute coronary syndrome (ACS) or at planned coronary stenting. Two main questions have always been related to DAT: the choice of drug for DAT and the duration of DAT. If the first question is now almost resolved (ticagrelor or prasugrel combined with ASA are preferred in most cases of ACS and clopidogrel combined with ASA is preferred for planned stenting), then the problems of DAT duration continue to be discussed. Current view on DAT can be described by the word "individualization", which means making a separate decision on the duration of DAT depending on the patient's characteristics and on the ratio of hemorrhagic and ischemic risks. To facilitate the decision on the duration of DAT the use of standardized PRECISE-DAPT and DAPT scales is currently recommended. Their values allow us to conclude what DAT duration is safe and effective. The data from the completed clinical studies STOP-DAPT-2 and SMART-CHOICE suggest that in the near future DAT duration will be shortened. In both of these studies, the shorter DAT was superior to the DAT of standard duration in terms of safety criteria and was comparable to it in terms of effectiveness. Another important change, as it seems, should be expected in the basic rules of antithrombotic treatment after coronary stenting in patients with atrial fibrillation. In this case, the need to combine DAT with oral anticoagulant (OAC) is associated with a worse prognosis due to the high probability of bleeding. Several studies with relatively similar design - PIONEER-AF, RE-DUAL-PCI, and especially AUGUSTUS - showed that from the first days after coronary stenting the combination of any of non-vitamin K antagonist OACs with a P2Y12 inhibitor (without ASA) may be safer and no less effective treatment option compared to the "triple" therapy (DAT + OAK).

double antiplatelet therapy, acetylsalicylic acid, P2Y12 inhibitor, acute coronary syndrome, coronary stenting, duration, bleeding