This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies.
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.
We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B).
Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.From the Norwegian Knowledge Centre for the Health Services and Department of Medicine (Dr Vandvik), Innlandet Hospital Trust Gjøvik, Gjøvik, Norway; Department of Cardiovascular Medicine and Cleveland Clinic Coordinating Center for Clinical Research (C5Research) (Dr Lincoff), Cleveland Clinic, Cleveland, OH; Department of Medicine (Dr Gore), University of Massachusetts Medical School, Worcester, MA; Department of Medicine (Dr Gutterman), Medical College of Wisconsin, Milwaukee, WI; Department of Medicine (Dr Sonnenberg), University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ; Iberoamerican Cochrane Centre (Dr Alonso-Coello), CIBERESP-IIB Sant Pau, Barcelona, Spain; Department of Medicine and Department of Clinical Epidemiology and Biostatistics (Dr Akl), State University of New York at Buffalo, Buffalo, NY; Stanford Stroke Center (Dr Lansberg), Stanford University Medical Center, Palo Alto, CA; and Department of Clinical Epidemiology and Biostatistics (Dr Guyatt) and Department of Medicine (Drs Guyatt and Spencer), McMaster University, Hamilton, ON, Canada.
Correspondence to: Frederick A. Spencer, MD, Department of Medicine, McMaster University, St. Joseph’s Health Care, 50 Charlton Ave E, Hamilton, ON, L8N 4A6, Canada; e-mail: firstname.lastname@example.org
Author contributions: As Topic Editor, Dr Vandvik oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Vandvik: served as Topic Editor.
Dr Lincoff: served as a panelist.
Dr Gore: served as a panelist.
Dr Gutterman: served as a panelist.
Dr Sonnenberg: served as a resource consultant.
Dr Alonso-Coello: served as a panelist.
Dr Akl: served as a panelist.
Dr Lansberg: served as a panelist.
Dr Guyatt: served as a panelist.
Dr Spencer: served as Deputy Editor.
Financial/nonfinancial disclosures: The authors of this guideline provided detailed conflict of interest information related to each individual recommendation made in this article. A grid of these disclosures is available online at http://chestjournal.chestpubs.org/content/141/2_suppl/e637S/suppl/DC1. In summary, the authors have reported to CHEST the following conflicts of interest: Dr Lincoff is Director of the Cleveland Clinic Coordinating Center for Clinical Research (C5Research), which has research grants from Anthera Pharmaceuticals, Inc; AstraZeneca; Bristol-Myers Squibb; Eli Lilly and Company; Kai Pharmaceuticals, Inc; Pfizer, Inc; Hoffmann La-Roche Inc; Novartis AG; Sanofi-Aventis LLC; Merck/Schering-Plough; Scios, Inc; Takeda Pharmaceutical Company Limited, and Johnson & Johnson. He has received honoraria for consultations or advisory board activities from AstraZeneca; Avanir Pharmaceuticals; Baxter; Bristol-Myers Squibb; Ikaria, Inc; Hoffmann La-Roche Inc; and Merck/Schering-Plough. Dr Gutterman has had the following relationships that are entirely unrelated to the AT9 guidelines: ACCP President, GlaxoSmithKline plc grant to study vasodilation in adipose tissue, National Institutes of Health grant to study human coronary dilation, and GE Healthcare consultation on a study for ECG evaluation of chronic heart disease. Dr Guyatt is co-chair of the GRADE Working Group. Drs Vandvik, Alonso-Coello, and Akl are members of and prominent contributors to the GRADE Working Group. Drs Gore, Sonnenberg, Lansberg, and Spencer have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors played no role in the development of these guidelines. Sponsoring organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Guideline panel members, including the chair, and members of the Health & Science Policy Committee are blinded to the funding sources. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.
Other contributions: We thank Louis Kuritzky, MD, for providing his frontline primary-care clinician perspective on the content of this article, John You, MD, for methodologic contributions (triple therapy in patients with acute LV thrombus), and Colin Baigent, MD, for sharing his methodologic expertise on primary prevention of cardiovascular disease with aspirin
Endorsements: This guideline is endorsed by the American Association for Clinical Chemistry, the American College of Clinical Pharmacy, the American Society of Health-System Pharmacists, the American Society of Hematology, and the International Society of Thrombosis and Hematosis.
Additional information: The supplement Tables can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/141/2_suppl/e637S/suppl/DC1.
Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.
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