p.42 抽出テキスト
CLINICAL STATEMENTS AND GUIDELINES August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168 Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline MI, ischemic heart disease, and cardiac arrest.12 Wildfire smoke can be carried long distances, exposing individuals thousands of miles from the source.11 The population health impact of wildfires is projected to increase in the coming years because of climate change–related increases in temperature and changes in precipitation patterns, as well as increased human habitation in wildland-urban interfaces.22 Minimizing exposure to these environmental extremes may improve outcomes for individuals with CCD. 4.3 Medical Therapy to Prevent Cardiovascular Events and Manage Symptoms 4.3.1 Antiplatelet Therapy and Oral Anticoagulants Recommendations for Antiplatelet Therapy and Oral Anticoagulants Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations Antiplatelet Therapy Without Oral Anticoagulants 1 A 1 In patients with CCD and no indication for oral anticoagulant therapy, low-dose aspirin 81 mg (75-100 mg) is recommended to reduce atherosclerotic events.*1–3 1 A 2 In patients with CCD treated with PCI, dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel for 6 months post PCI followed by single antiplatelet therapy (SAPT) is indicated to reduce MACE and bleeding events.*4–7 2a A 3 In select patients with CCD treated with PCI and a drug-eluting stent (DES) who have completed a 1- to 3-month course of DAPT, P2Y12 inhibitor monotherapy for at least 12 months is reasonable to reduce bleeding risk.8–12 2b A 4 In patients with CCD who have had a previous MI and are at low bleeding risk, extended DAPT beyond 12 months for a period of up to 3 years may be reasonable to reduce MACE.*13,14 2b B-R 5 In patients with CCD and a previous history of MI without a history of stroke, transient ischemic attack (TIA), or ICH, vorapaxar may be added to aspirin therapy to reduce MACE.15–17 2b B-R 6 In patients with CCD, the use of DAPT after CABG may be useful to reduce the incidence of saphenous vein graft occlusion.18 3: No benefit A 7 In patients with CCD without recent ACS or a PCI-related indication for DAPT, the addition of clopidogrel to aspirin therapy is not useful to reduce MACE.*19 3: Harm A 8. In patients with CCD and previous stroke, TIA, or ICH, vorapaxar should not be added to DAPT because of increased risk of major bleeding and ICH.15,20 3: Harm B-R 9 In patients with CCD and previous stroke, TIA, or ICH, prasugrel should not be used because of risk of significant or fatal bleeding.21 3: Harm B-R 10. In patients with CCD, chronic nonsteroidal anti-inflammatory drugs should not be used because of increased cardiovascular and bleeding complications.*22 Antiplatelet Therapy With Direct Oral Anticoagulant (DOAC) 1 B-R 11. In patients with CCD who have undergone elective PCI and who require oral anticoagulant therapy, DAPT for 1 to 4 weeks followed by clopidogrel alone for 6 months should be administered in addition to DOAC.†23 2a B-R 12. In patients with CCD who have undergone PCI and who require oral anticoagulant therapy, continuing aspirin in addition to clopidogrel for up to 1 month is reasonable if the patient has a high thrombotic risk and low bleeding risk.*23–25 2b B-R 13. In patients with CCD who require oral anticoagulation and have a low atherothrombotic risk, discontinuation of aspirin therapy with continuation of DOAC alone may be considered 1 year after PCI to reduce bleeding risk.*26 2b C-LD 14. In patients with CCD who require oral anticoagulation, DOAC monotherapy may be considered if there is no acute indication for concomitant antiplatelet therapy.27–29 Antiplatelet Therapy and Low-Dose DOAC 2a B-R 15. In patients with CCD without an indication for therapeutic DOAC or DAPT and who are at high risk of recurrent ischemic events but low-to-moderate bleeding risk, the addition of low-dose rivaroxaban 2.5 mg twice daily to aspirin 81 mg daily is reasonable for long-term reduction of risk for MACE.30–32 DAPT and Proton Pump Inhibitor (PPI) 2a B-R 16. In patients with CCD on DAPT, the use of a PPI can be effective in reducing gastrointestinal bleeding risk.*33 *Modified from the 2016 ACC/AHA Guideline Focused Update on DAPT.34 †Modified from the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.35 Synopsis These recommendations on the use of antiplatelet therapy in patients with CCD update and supplement the 2016 AHA/ACC guideline for DAPT.34 Significant benefits remain for aspirin use in secondary prevention.2,36,37 The use of DAPT can be considered in those who have high thrombotic risk and low bleeding risk. Figure 9 summarizes recommendations for antiplatelet therapy in CCD. The use of validated risk scores to address bleeding risk can be useful in choice and duration of antiplatelet therapy. The more frequently used risk calculators are PRECISE DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy), DAPT, and PARIS (Patterns of Non-Adherence to Antiplatelet Regimen in Stented Patients) risk scores.18–20 Several clinical trials have evaluated strategies for concurrent use of antiplatelet agents and DOACs in patients with atherosclerotic disease. The breadth and consistency of trials evaluating the efficacy and safety of DOAC use with or without antiplatelet therapy among patients with CCD and with or without AF is modest.27,28,30-32,38–44 The combination of antiplatelet Recommendations for Antiplatelet Therapy and Oral Anticoagulants (Continued ) COR LOE Recommendations Downloaded from http://ahajournals.org by on October 7, 2026