What is the purpose of Dual Antiplatelet Therapy (DAPT)?

From the Guidelines

Dual antiplatelet therapy (DAPT) should be used for at least 6 months after drug-eluting stent placement and at least 1 month after bare metal stent placement, with the option to extend or shorten duration based on individual patient risk factors, as recommended by the 2021 ACC/AHA/SCAI guideline 1. The goal of DAPT is to prevent local thrombotic complications related to stent implantation and to reduce systemic atherothrombotic events.

Key Considerations

• For patients with acute coronary syndrome (ACS), DAPT should be continued for at least 6 months, with the option to extend beyond 12 months for high-risk patients 1.
• For patients with stable ischemic heart disease (SIHD), DAPT should be continued for at least 1 month, with the option to extend to 12 months or more based on individual patient risk factors 1.
• Patients with high bleeding risk may require shorter durations of DAPT (3-6 months), while those with low bleeding risk may benefit from extended DAPT (>12 months) 1.

DAPT Regimens

• Aspirin (75-100 mg daily) plus a P2Y12 inhibitor such as clopidogrel (75 mg daily), ticagrelor (90 mg twice daily), or prasugrel (10 mg daily) are commonly used DAPT regimens.
• The choice of P2Y12 inhibitor and duration of DAPT should be individualized based on patient risk factors and clinical presentation.

Monitoring and Management

• Regular monitoring for bleeding complications is essential, and patients should be advised to report any unusual bleeding or bruising.
• DAPT should be temporarily interrupted 5-7 days before elective surgery, though aspirin may be continued for cardiac procedures. The 2021 ACC/AHA/SCAI guideline provides a comprehensive framework for the use of DAPT in patients with coronary artery disease, and clinicians should use a Heart Team approach to individualize care decisions 1.

From the FDA Drug Label

In patients ≥75 years of age, prasugrel is generally not recommended, because of the increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior myocardial infarction [MI]) where its effect appears to be greater and its use may be considered Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The use of DAPT (Dual Antiplatelet Therapy) with prasugrel and aspirin is recommended for patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI).

• Key components of DAPT: prasugrel and aspirin
• Dosage: prasugrel 10 mg orally once daily and aspirin 75 mg to 325 mg daily
• Special considerations: use with caution in patients ≥75 years of age, patients with a history of bleeding, and patients with a propensity to bleed 2

From the Research

Dual Antiplatelet Therapy (DAPT)

• DAPT is a treatment that combines two antiplatelet agents, typically aspirin and a P2Y12 inhibitor, to prevent blood clots from forming in patients with coronary artery disease 3.
• The standard duration of DAPT varies depending on the patient's condition, with a minimum of 6 months recommended after elective drug-eluting stent placement and at least 12 months after acute coronary syndrome (ACS) 4, 5.

Benefits and Risks of DAPT

• DAPT has been shown to reduce the risk of stent thrombosis and recurrent ischemic events in patients with ACS 3, 6.
• However, long-term DAPT increases the risk of major bleeding, requiring a delicate balance between anti-ischemic benefit and bleeding risk 3, 4.
• The choice of P2Y12 inhibitor and the duration of DAPT should be tailored to the individual patient, taking into account their thrombotic and bleeding risks 4, 6.

P2Y12 Inhibitors

• Prasugrel and ticagrelor are newer P2Y12 inhibitors that have demonstrated greater efficacy than clopidogrel in reducing ischemic events 6.
• Ticagrelor 60 mg twice daily has been shown to be safe and effective in patients undergoing intracranial stenting, with lower rates of in-stent stenosis compared to clopidogrel 7.
• The optimal dose and duration of P2Y12 inhibitors for DAPT are still being studied, with ongoing trials aiming to establish the most effective regimens 4, 6.

Guidelines and Recommendations

• Current guidelines recommend DAPT with aspirin and a P2Y12 inhibitor for at least 6 months after drug-eluting stent placement and at least 12 months after ACS 3, 5.
• The American College of Cardiology/American Heart Association Guidelines suggest that DAPT should be continued for at least 1 year in patients with ACS, with possible extension beyond 1 year in selected patients 5.
• Risk scores, such as the DAPT score, are available to help guide decisions on the optimal duration and choice of DAPT regimen for individual patients 4.