Grey zones on dual antiplatelet therapy. Expert opinion

Clinical guidelines, while representing an objective reference to perform appropriate treatment choices, contain grey zones, where recommendations are not supported by solid evidence. In a conference held in Bergamo in October 2018, an attempt was made to highlight some of the main gray zones in Cardiology and, through a comparison between experts, to draw shared conclusions that can illuminate our clinical practice. This manuscript contains the statements of the symposium concerning the controversies regarding dual antiplatelet therapy (DAPT). The manuscript represents the organization of the meeting, with an initial review of current guidelines on this topic, followed by an expert presentation of pros (white) and cons (black) related to the identified "gaps of evidence". For every issue is then reported the response derived from the votes of the experts and the public, the discussion and, finally, the highlights, which are intended as practical "take home messages" to be used in everyday clinical practice. The first topic concerns the utility of scores to shorten the duration of DAPT in patients at high bleeding risk. The second issue examines the appropriateness of the level of evidence to prolong DAPT beyond 1 year in patients at high ischemic risk. The last "gap in evidence" concerns the possibility of adopting the single antiplatelet therapy plus an anticoagulant vs the triple therapy in patients with atrial fibrillation and acute coronary syndrome. The work has also been implemented with evidences deriving from important randomized studies published after the date of the Conference.