DAPT Recommendations
For patients with acute coronary syndrome (ACS) treated with PCI, dual antiplatelet therapy with aspirin 81 mg daily plus a P2Y12 inhibitor (preferably ticagrelor or prasugrel over clopidogrel) should be continued for at least 12 months, unless high bleeding risk mandates earlier discontinuation. 1
Core DAPT Regimen
Aspirin Component
- Daily dose: 81 mg (range 75-100 mg) - this is a Class I recommendation across all scenarios 1
P2Y12 Inhibitor Selection
For ACS with PCI:
- First choice: Ticagrelor - reasonable to prefer over clopidogrel (Class IIa) 1
- Second choice: Prasugrel - reasonable to prefer over clopidogrel IF patient has no history of stroke/TIA and is not at high bleeding risk (Class IIa) 1
- Contraindication: Never use prasugrel in patients with prior stroke or TIA (Class III: Harm) 1
- Clopidogrel is acceptable but less preferred
Duration by Clinical Scenario
ACS Treated with PCI (BMS or DES)
- Minimum duration: 12 months (Class I, Level B-R) 1
- Extension beyond 12 months: May be reasonable if patient has tolerated DAPT without bleeding complications and is not at high bleeding risk 1
ACS Treated with Medical Therapy Alone (No Revascularization)
- Duration: At least 12 months with clopidogrel or ticagrelor (Class I, Level B-R) 1
- Ticagrelor preferred over clopidogrel for NSTE-ACS (Class IIa) 1
STEMI Treated with Fibrinolytic Therapy
- Minimum: 14 days (Class I, Level A) 1
- Ideal: 12 months (Level C-EO) 1
- Only clopidogrel is recommended in this scenario 1
ACS Treated with CABG
- Resume P2Y12 inhibitor after CABG to complete 12 months total DAPT from the ACS event (Class I, Level C-LD) 1
High Bleeding Risk Modifications
Early discontinuation at 6 months may be reasonable if: 1
- Patient develops high bleeding risk (e.g., requires oral anticoagulation)
- High risk of severe bleeding complication (e.g., major intracranial surgery planned)
- Significant overt bleeding occurs
This applies specifically to DES patients (Class IIb, Level C-LD).
Important Caveats
The 12-month recommendation is based on extrapolation: The landmark CURE trial that established this standard had a mean DAPT duration of 9 months, not 12 2. Subsequent trials (PLATO with ticagrelor, TRITON-TIMI 38 with prasugrel) had median durations of 9 and 15 months respectively 2.
Emerging evidence suggests shorter durations may be appropriate: Recent network meta-analyses suggest 1-3 month DAPT may reduce bleeding without increasing ischemic events 3, 4, but these findings have not yet been incorporated into Class I guideline recommendations. The 2016 ACC/AHA guidelines remain the authoritative standard, maintaining 12 months as the default 1.
Clinical practice often diverges from guidelines: Real-world data shows up to 85% of high bleeding risk patients still receive 12 months of DAPT despite recommendations for shorter durations 5, suggesting clinicians remain conservative in practice.
Bleeding risk should drive decision-making: The net clinical benefit of DAPT is maximized by assessing bleeding risk rather than solely focusing on ischemic risk 2. Patients at high bleeding risk derive no clear benefit from prolonged DAPT and experience excess bleeding 2.