Dual Antiplatelet Therapy After PCI

For ACS treated with PCI, begin with a planned 12-month course of DAPT using aspirin plus a potent P2Y12 inhibitor, ticagrelor or prasugrel, unless bleeding risk, an oral-anticoagulation indication, or a competing contraindication changes the net clinical balance. ACS guidance and contemporary summaries continue to identify 12 months as the default; clopidogrel is generally reserved when ticagrelor or prasugrel cannot be used or when bleeding risk is high. JAMA+3JAMAShort-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in ...PubMedIndividualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based ReviewESCDual antiplatelet therapy for the general cardiologist: recent ...ESCNew trial evidence on the use of blood thinners after coronary stenting

For PCI performed for chronic coronary syndrome, use aspirin plus clopidogrel for a conventional 6-month course in patients without high bleeding risk. Consider an abbreviated course in noncomplex PCI when ischemic risk is reasonable, there is no substantial residual coronary disease, and the bleeding consequence of continuing DAPT outweighs expected ischemic protection. PubMed+1PubMedAntiplatelet Therapy in Chronic Coronary Artery Disease Patients With a History of Angioplasty. When is Aspirin Not Enough? A Systematic Review - PMCESCDual antiplatelet therapy for the general cardiologist: recent ...

The duration decision is not determined by stent type alone. Contemporary drug-eluting stent safety and randomized trials support 1- to 3-month DAPT followed by P2Y12 inhibitor monotherapy in selected patients, and the 2021 ACC/AHA/SCAI revascularization guideline assigned this approach a class IIa recommendation after stent implantation in stable CAD and ACS. This option requires a planned transition rather than unstructured early discontinuation of either agent. PubMedPubMedShortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical Review

Calculate the PRECISE-DAPT score when duration is uncertain. A score of 25 or greater defines high bleeding risk in the cited pooled analysis. Among 14,963 PCI patients from eight randomized trials, prolonged DAPT reduced ischemic events in patients with PRECISE-DAPT scores below 25, including those undergoing complex PCI, but increased bleeding in patients with scores of 25 or greater without additional ischemic benefit. jacc+1jaccDual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary StentingjaccTwilight, the Dawn of a New Era of Aspirin-Free PCI?∗ | JACC

In patients meeting high-bleeding-risk criteria, 1- or 3-month DAPT after PCI lowered major or clinically relevant bleeding, major bleeding, and cardiovascular mortality compared with standard-duration DAPT in a randomized-trial meta-analysis. Ischemic outcomes, including MACE and stent thrombosis, were similar across abbreviated and standard-duration strategies, although patients receiving oral anticoagulation were excluded from that meta-analysis. Oxford AcademicOxford AcademicDual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials | European Heart Journal | Oxford Academic

Choose the single-antiplatelet agent after abbreviated DAPT deliberately. In high-bleeding-risk trial populations, aspirin or a P2Y12 inhibitor as monotherapy after short DAPT had no observed difference in bleeding or ischemic protection in the meta-analysis; however, P2Y12-monotherapy evidence varies by the agent, clinical presentation, and trial design. Oxford AcademicOxford AcademicDual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials | European Heart Journal | Oxford Academic

For a patient undergoing PCI who also requires long-term oral anticoagulation, use only a brief period of triple therapy with aspirin, a P2Y12 inhibitor, and oral anticoagulation. Stop aspirin after 1 to 4 weeks, then continue oral anticoagulation plus a P2Y12 inhibitor. This is a class I recommendation cited for PCI patients receiving oral anticoagulation. jaccjaccShort Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months?∗ | JACC: Cardiovascular Interventions

The rationale is clinically consequential: triple antithrombotic therapy has been associated with greater than a threefold increased major-bleeding risk. Compared with prolonged triple therapy, oral anticoagulation plus a P2Y12 inhibitor reduces bleeding without compromising death or MI in the cited evidence base, although meta-analysis data suggest that very early aspirin discontinuation may increase stent thrombosis. jacc+1jaccShort Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months?∗ | JACC: Cardiovascular InterventionsOxford AcademicAntithrombotic therapy according to baseline bleeding risk in patients with atrial fibrillation undergoing percutaneous coronary intervention: applying the PRECISE-DAPT score in RE-DUAL PCI

Before shortening triple therapy toward the earliest end of the 1- to 4-week interval, explicitly weigh early stent-thrombosis concern against bleeding liability. The extent of the potential stent-thrombosis tradeoff in high-bleeding-risk patients requiring oral anticoagulation remains uncertain; avoid applying non-anticoagulated short-DAPT results directly to this group. jacc+1jaccShort Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months?∗ | JACC: Cardiovascular InterventionsOxford AcademicDual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials | European Heart Journal | Oxford Academic

For selected patients undergoing PCI, a 1- to 3-month DAPT course followed by P2Y12 inhibitor monotherapy is the principal abbreviated strategy reflected in U.S. revascularization guidance. In ACS patients undergoing DES PCI, a network meta-analysis found that 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy reduced major bleeding without increasing MACCE compared with 12 months of DAPT. PubMed+1PubMedShortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical ReviewACCShort-Term DAPT After DES in Patients With ACS - American College of Cardiology

Ticagrelor-based evidence is strongest for patients who complete an initial 3-month DAPT period. In TWILIGHT, 3 months of DAPT followed by ticagrelor monotherapy reduced clinically relevant bleeding versus continued ticagrelor plus aspirin without increasing death, MI, or stroke; the finding was confirmed in patients aged 65 years or older. NatureNatureDe-escalation or abbreviation of dual antiplatelet therapy in acute ...

Do not assume that every short-DAPT regimen is equivalent in ACS. STOPDAPT-2 found lower bleeding with 1 month of DAPT followed by clopidogrel monotherapy, but identified a possible interaction suggesting excess net adverse ischemic events among ACS patients. This makes 1-month clopidogrel monotherapy a less secure default for unselected ACS PCI than a potent P2Y12-monotherapy strategy. ACC+1ACCShort and Optimal Duration of Dual Antiplatelet Therapy After ...ACCShort-Term DAPT After DES in Patients With ACS - American College of Cardiology

Avoid immediate substitution of DAPT with P2Y12 monotherapy at the time of PCI. In STOPDAPT-3, immediate prasugrel monotherapy was not beneficial and could be harmful, particularly in ACS; DAPT remained the standard during the first month after coronary stent implantation. ACCACCShort and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-3 - American College of Cardiology

At 1 month, determine whether the patient is on a planned high-bleeding-risk or oral-anticoagulation pathway. For patients requiring oral anticoagulation, aspirin should be stopped no later than the individualized 1- to 4-week triple-therapy interval. For non-anticoagulated patients, do not interpret the 1-month landmark as universal permission to stop DAPT; ACS phenotype, P2Y12 agent, and ischemic risk remain decisive. jacc+3jaccShort Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months?∗ | JACC: Cardiovascular InterventionsACCShort and Optimal Duration of Dual Antiplatelet Therapy After Everolimus-Eluting Cobalt-Chromium Stent-3 - American College of CardiologyACCShort and Optimal Duration of Dual Antiplatelet Therapy After ...ACCShort-Term DAPT After DES in Patients With ACS - American College of Cardiology

At 3 months, reassess candidacy for P2Y12 monotherapy when bleeding risk is clinically important and the initial DAPT course has been completed without an ischemic event. Ticagrelor monotherapy after 3 months of DAPT reduced clinically relevant bleeding without an observed ischemic penalty in TWILIGHT. NatureNatureDe-escalation or abbreviation of dual antiplatelet therapy in acute ...

At 6 months, chronic coronary syndrome patients have reached the conventional DAPT endpoint. Continue beyond that point only when ischemic protection is expected to outweigh bleeding risk; extended therapy has its clearest rationale in low-bleeding-risk patients with higher ischemic risk. PubMed+1PubMedAntiplatelet Therapy in Chronic Coronary Artery Disease Patients With a History of Angioplasty. When is Aspirin Not Enough? A Systematic Review - PMCESCDual antiplatelet therapy for the general cardiologist: recent ...

At 12 months after ACS, do not automatically extend DAPT. Extension to 30 months reduced ischemic events and stent thrombosis in the DAPT trial but increased bleeding; the balance becomes less favorable with older age and with PRECISE-DAPT-defined high bleeding risk. jacc+1jaccDual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary StentingjaccAntithrombotic Management of Elderly Patients With Coronary Artery Disease