LAUSR

In accordance with the policy on clinical practice guidelines of the Spanish Society of Cardiology (SEC), this article presents the novel, pertinent, and conflicting aspects of the 2017 focused update on the use of dual antiplatelet therapy (DAPT) in coronary artery disease of the European Society of Cardiology (ESC) together with the European Association for Cardio-Thoracic Surgery. The preamble once again emphasizes that, although these recommendations are designed to support health care professionals in decision-making, the ultimate responsibility in each case lies with the professional and the patient. The authors use the opportunity to insist on the need for registries that verify the clinical reality to address these recommendations and to analyze the differences between them and the standard clinical practice. This year marked the 21st anniversary of the publication of the first clinical trial that established the superiority of DAPT over anticoagulation after percutaneous coronary intervention (PCI); the number of patients treated with DAPT is high and ever growing. The challenges facing DAPT have included the shift from a local target vessel strategy to a comprehensive protection strategy (fewer ischemic coronary artery complications and those of other territories), doubts about the optimal duration of treatment in different settings (whether the procedure was invasive or not and according to revascularization type), bleeding complications, influence of clinical variables, and comorbidities (eg, advanced age, diabetes mellitus, renal failure, need for anticoagulation). Because these variables mean that patients in clinical practice are often different from those selected in clinical trials, this guideline-update on the use of DAPT is both interesting and necessary. The guidelines uses the standard levels of evidence (A, B, C) and classes of recommendation (classes I, IIa, IIb, and III) and ends with a summary of the key messages and a succinct table showing the recommendations. One notable aspect of these guidelines, in contrast to others, is the high percentage of class I and III recommendations (27 of 64, 42%). Another interesting aspect is the additional on-line material, which briefly describes 18 clinical cases that clearly and specifically illustrate the practical application of the guidelines’ recommendations.