What are the indications for dual antiplatelet therapy (DAPT) in patients with stable coronary artery disease (CAD) besides acute coronary syndrome (ACS)?

From the Guidelines

Dual antiplatelet therapy (DAPT) in stable coronary artery disease outside of acute coronary syndrome is primarily indicated following percutaneous coronary intervention (PCI) with stent placement, with the standard regimen consisting of aspirin 81mg daily indefinitely plus a P2Y12 inhibitor for a duration that depends on stent type and bleeding risk. The indications for DAPT in patients with stable coronary artery disease (CAD) besides acute coronary syndrome (ACS) include:

• High-risk anatomical features, such as left main, bifurcation, or multiple stents
• Diabetes mellitus
• Prior stent thrombosis
• Patients who have undergone complex PCI, such as those with bifurcation lesions or multiple stents 1 The duration of DAPT depends on the type of stent used and the patient's bleeding risk. For bare metal stents, DAPT is recommended for at least 1 month, while drug-eluting stents typically require 6-12 months of therapy 1. In high bleeding risk patients, DAPT duration may be shortened to 1-3 months, while those at high ischemic risk and low bleeding risk may benefit from extended DAPT beyond 12 months 1. Some key points to consider when deciding on DAPT duration include:
• The type of stent used: drug-eluting stents typically require longer DAPT duration than bare metal stents
• The patient's bleeding risk: patients with high bleeding risk may require shorter DAPT duration
• The patient's ischemic risk: patients with high ischemic risk may benefit from extended DAPT duration
• The presence of high-risk anatomical features, such as left main or bifurcation lesions
• The presence of diabetes mellitus or prior stent thrombosis It is essential to individualize the decision on DAPT duration based on the patient's specific clinical characteristics and risk factors, as recommended by the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1.

From the Research

Indications for Dual Antiplatelet Therapy

Dual antiplatelet therapy (DAPT) is commonly used in patients with acute coronary syndrome (ACS) and those undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD). Besides ACS, the indications for DAPT in patients with stable CAD include:

• Patients undergoing PCI with drug-eluting stents (DES) 2
• Patients with stable CAD who have undergone coronary artery bypass grafting (CABG) or transcatheter aortic valve implantation (TAVI) 3
• Patients with peripheral artery disease (PAD) who have undergone revascularization procedures 3
• Patients with carotid artery disease who have undergone carotid artery stenting (CAS) 3

Duration of Dual Antiplatelet Therapy

The optimal duration of DAPT for patients with stable CAD is uncertain and depends on various factors, including the patient's clinical presentation, baseline risk profile, and management strategy. Studies have shown that:

• Shorter durations of DAPT (3-6 months) may be non-inferior to longer durations (12-24 months) in terms of major adverse cardiovascular events (MACE), but may reduce the risk of major bleeding 2, 4
• Prolonged DAPT durations (18-48 months) may reduce the incidence of myocardial infarction and stent thrombosis, but may increase the risk of major bleeding and all-cause mortality 2
• The choice of optimal DAPT regimen and duration requires a tailored approach based on individual patient characteristics and risk profiles 2, 3

Specific Patient Populations

DAPT may be beneficial in specific patient populations, including:

• Patients with stable CAD and diabetes, who may benefit from ticagrelor and aspirin therapy 3
• Patients with atrial fibrillation who have undergone PCI, who may require individualized antiplatelet therapy based on their bleeding risk 3
• Patients with PAD who have undergone revascularization procedures, who may benefit from DAPT with aspirin and clopidogrel or other antiplatelet agents 3