From the Guidelines
The recommended duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stent placement is at least 12 months for patients with acute coronary syndrome (ACS) and at least 6 months for patients with stable ischemic heart disease, according to the 2016 ACC/AHA guideline focused update on duration of DAPT in patients with coronary artery disease 1.
DAPT Duration Recommendations
The American College of Cardiology (ACC) and American Heart Association (AHA) guidelines recommend the following DAPT durations:
- For patients with ACS treated with DAPT after bare metal stent (BMS) or drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy should be given for at least 12 months 1.
- For patients treated with DAPT, a daily aspirin dose of 81 mg (range, 75 mg to 100 mg) is recommended 1.
- For patients with ACS treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 1.
Factors Influencing DAPT Duration
The decision to extend or shorten DAPT duration should be based on individual patient factors, including:
- Risk of stent thrombosis
- Risk of bleeding complications
- History of stroke or transient ischemic attack (TIA)
- Use of oral anticoagulant therapy
- Development of significant overt bleeding
Personalized Recommendations
It is essential to consult with the treating cardiologist for personalized recommendations, as they may adjust DAPT duration based on specific stent type, location, patient risk factors, and bleeding risk. The rationale for DAPT is to prevent stent thrombosis while the stent endothelializes, and drug-eluting stents take longer to heal than bare metal stents, hence the longer DAPT duration. However, prolonged DAPT increases bleeding risk, so duration must be balanced against individual patient factors 1.
From the Research
Duration of Dual Antiplatelet Therapy (DAPT) after Percutaneous Coronary Intervention (PCI)
The recommended duration of DAPT after PCI with stent placement is a topic of ongoing debate. Several studies have investigated the optimal duration of DAPT to balance the risk of ischemic events and bleeding complications.
- A study published in the Journal of the American College of Cardiology in 2015 2 found that 6-month DAPT was noninferior to 24-month DAPT in patients with drug-eluting stents, with similar rates of death, myocardial infarction, and major bleeding.
- A meta-analysis published in the American Journal of Therapeutics in 2017 3 found that short-term DAPT (less than 6 months) had similar incidence of stent thrombosis, myocardial infarction, and death compared to standard duration DAPT, but with lower rates of major bleeding.
- A review published in the American Journal of Health-System Pharmacy in 2016 4 suggested that DAPT for 12 months should remain the standard recommendation after PCI with drug-eluting stent implantation, but that shorter or longer durations may be considered based on individual patient risk factors.
- An article published in the European Heart Journal in 2016 5 proposed a personalized approach to determining the optimal duration of DAPT, taking into account the individualized risks of ischemic and bleeding events.
- A summary of existing evidence published in Cardiovascular Diagnosis and Therapy in 2018 6 highlighted the importance of balancing anti-ischemic protection and bleeding risk when determining the optimal duration of DAPT, and emphasized the need for treatment individualization.
Key Findings
- Short-term DAPT (less than 6 months) may be as effective as standard duration DAPT, with lower rates of major bleeding 3, 2.
- Extended DAPT (beyond 12 months) may reduce the risk of ischemic events, but increases the risk of bleeding and may not improve overall mortality 5, 3.
- A personalized approach to determining the optimal duration of DAPT is recommended, taking into account individual patient risk factors and the balance between ischemic and bleeding risk 5, 6.