ACC/AHA2016：抗血小板薬 2 剤併用療法：DAPT治療期間アップデートガイドライン

抗血小板薬 2 剤併用療法：DAPT治療期間アップデートガイドライン

2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

http://content.onlinejacc.org/article.aspx?articleid=2507082
J Am Coll Cardiol. 2016;():. doi:10.1016/j.jacc.2016.03.513

冠動脈性心疾患（CAD)患者の dual antiplatelet therapy (DAPT)治療期間に関するアップデートガイドラインの注意すべきキーポイント
（誤訳高頻度のため、本文併記した）

• The scope of this focused update is limited to addressing recommendations on duration of DAPT (aspirin plus a P2Y12 inhibitor) in patients with coronary artery disease (CAD).：アスピリン+P2Y12阻害剤併用に限定した話題
• Intensification of antiplatelet therapy, with the addition of a P2Y12 inhibitor to aspirin monotherapy, and prolongation of DAPT, necessitate a fundamental tradeoff between decreasing ischemic risk and increasing bleeding risk. Decisions regarding treatment with and duration of DAPT require a thoughtful assessment of the benefit/risk ratio, integration of study data, and patient preference.：アスピリン単剤にP2Y12阻害剤を加えることは、虚血性リスク軽減と出血リスク増加のトレードオフ；ベネフィット/リスク比、研究データ集積、患者の好みまで熟考すべき
• Recommendations in the document apply specifically to duration of P2Y12 inhibitor therapy in patients　 with CAD treated with DAPT. Aspirin therapy should almost always be continued indefinitely in patients with CAD.：DAPT治療されているCAD患者でのP2Y12阻害剤治療期間に特異的記載
• Lower daily doses of aspirin, including in patients treated with DAPT, are associated with lower bleeding complications and comparable ischemic protection compared with higher doses of aspirin. The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range 75–100 mg).：DAPT治療患者に於ける、低用量アスピリンは出血合併症を軽減し虚血性予防は同等。推奨投与量は 81 mg (range 75–100 mg).
• In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).：drug-eluting stent (DES) 植込後DAPT治療安定虚血性心疾患患者では、クロピドグレルとしてのP2Y12阻害治療は最低6ヶ月。bare-metal stent (BMS)植込後安定虚血性心疾患患者では1ヶ月最低投与すべき。
• In patients with SIHD treated with DAPT after BMS or DES implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT with clopidogrel for longer than 1 month in patients treated with BMS or longer than 6 months in patients treated with DES may be reasonable (Class IIb).：安定期虚血性心疾患においてBMS治療1ヶ月超、DES治療6ヶ月超のそれぞれクロピドグレルを含むDAPT治療は出血合併症無ければ耐用性十分で合理的
• In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).：BMS、DES植込後DAPT治療中のST非上昇、ST上昇型急性冠症候群患者は最低12ヶ月投与すべき
• In patients with ACS (NSTE-ACS or STEMI) treated with coronary stent implantation who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk (e.g., prior bleeding on DAPT, coagulopathy, oral anticoagulant use), continuation of DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months may be reasonable (Class IIb). A new risk score (the “DAPT score”), derived from the Dual Antiplatelet Therapy study, may be useful for decisions about whether to continue (prolong or extend) DAPT in patients treated with coronary stent implantation.：冠動脈ステントACS（ST非上昇、ST上昇心筋梗塞）患者で、出血合併症なし・出血リスク高度でないDAPT耐用患者では、12ヶ月以上治療は合理的。DAPTスコアというあたらしいリスクスコアが継続可否の意思決定に有用
• In patients with ACS (NSTE-ACS or STEMI) treated with DAPT after coronary stent implantation and in patients with NSTE-ACS treated with medical therapy alone (without revascularization), it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa). Among those who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack, it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa).：冠動脈ステント後DAPT治療および薬物治療のみ（血管再建せず）NSTE-ACS患者では、P2Y12阻害剤治療継のためのクロピドグレルよりチカグレロル（アストラゼネカ）使用されるのは合理的；出血合併症リスク高くない、卒中・TIA病歴なしの患者において、クロピドグレルよりプラスグレル（エフィエント）を維持的P2Y12阻害剤治療のため選択するのは合理的
• In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).：CABG施行DAPT治療ACS患者治療中ACS（ST非上昇-ACSあるいはSTEMI)患者では、P2Y12阻害剤治療はCABG後に再開、ACS後12ヶ月間DAPT治療完遂すべき
• In patients with STEMI treated with DAPT in conjunction with fibrinolytic therapy, P2Y12 inhibitor therapy (clopidogrel) should be continued for a minimum of 14 days and ideally at least 12 months (Class I).：血栓溶解療法併用DAPT治療STEMI患者において、P2Y12阻害剤（クロピドグレル）は14日間継続すべきで、理想的には12ヶ月
• Elective noncardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).：待機的非心臓手術はBMS挿入後30日間、DES挿入後最適なのは6ヶ月間遅延すべき。手術治療すべき、冠動脈ステント後DAPT治療患者、P2Y12阻害剤中止考慮患者では、可能な限りアスピリン継続し、P2Y12血小板受容体阻害剤は手術後早期に再開すべき
• Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and ACS, Interventions and ACS, Interventions and Coronary Artery Disease

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 Development and Validation of a Prediction Rule for Benefit and Harm of Dual Antiplatelet Therapy Beyond 1 Year After Percutaneous Coronary Intervention
Robert W. Yeh, Met. al. ; for the DAPT Study Investigators
JAMA. Published online March 29, 2016. doi:10.1001/jama.2016.3775