What are the indications for Dual Antiplatelet Therapy (DAPT)?

From the Guidelines

Dual Antiplatelet Therapy (DAPT) is primarily indicated for patients with acute coronary syndromes (ACS), those undergoing percutaneous coronary intervention (PCI) with stent placement, and individuals with recent ischemic stroke or high-risk transient ischemic attack (TIA). The standard DAPT regimen consists of aspirin (81-100 mg daily) combined with a P2Y12 inhibitor such as clopidogrel (75 mg daily), ticagrelor (90 mg twice daily), or prasugrel (10 mg daily) 1. For patients with ACS or coronary stenting, DAPT is typically recommended for 6-12 months, with longer durations for drug-eluting stents or high ischemic risk patients 1. Following ischemic stroke or TIA, DAPT with aspirin and clopidogrel is usually given for 21-90 days. DAPT duration should be individualized based on the patient's bleeding risk versus thrombotic risk 1. Some key points to consider when deciding on DAPT duration include:

• In patients with ACS who are managed with medical therapy alone and treated with DAPT, it is recommended to continue P2Y12 inhibitor therapy for 12 months 1.
• Ticagrelor is recommended over clopidogrel, unless the bleeding risk outweighs the potential ischemic benefit 1.
• In patients with prior MI at high ischemic risk who are managed with medical therapy alone and have tolerated DAPT without a bleeding complication, treatment with DAPT in the form of ticagrelor 60 mg b.i.d. on top of aspirin for longer than 12 months and up to 36 months may be considered 1.
• Patients with peripheral arterial disease, particularly after revascularization procedures, may also benefit from DAPT 1. The therapy works by inhibiting platelet aggregation through two different mechanisms: aspirin blocks the cyclooxygenase pathway while P2Y12 inhibitors block ADP-mediated platelet activation, providing more comprehensive protection against thrombotic events than either agent alone. It's worth noting that the most recent guidelines from the European Society of Cardiology (2024) recommend DAPT consisting of aspirin 75–100 mg and clopidogrel 75 mg daily for up to 6 months as the default antithrombotic strategy after PCI-stenting in patients with chronic coronary syndrome and no indication for oral anticoagulation 1.

From the FDA Drug Label

1 INDICATIONS AND USAGE 1.1 Acute Coronary Syndrome (ACS) 1.2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease

The indications for Dual Antiplatelet Therapy (DAPT), in the context of clopidogrel, are:

• Acute Coronary Syndrome (ACS)
• Recent MI, Recent Stroke, or Established Peripheral Arterial Disease 2

From the Research

Indications for Dual Antiplatelet Therapy (DAPT)

The indications for DAPT therapy include:

• Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) 3, 4, 5
• Patients with stable coronary artery disease, particularly those with diabetes, where ticagrelor and aspirin can reduce cardiovascular events 3
• Patients with atrial fibrillation after PCI, where the duration of antiplatelet therapy depends on individual characteristics and bleeding risk 3
• Patients undergoing coronary artery bypass grafting or transcatheter aortic valve implantation, where aspirin monotherapy is preferred 3
• Patients with peripheral artery disease, where the duration of antiplatelet therapy depends on the scenario, and adding vorapaxar and cilostazol may be beneficial for secondary prevention and claudication, respectively 3
• Patients with carotid artery disease, particularly those with transient ischemic attack or stroke, where combining aspirin and clopidogrel is more effective than aspirin alone 3

Duration of DAPT Therapy

The optimal duration of DAPT therapy is still debated, but studies suggest:

• Short-term DAPT (3-6 months) may be equivalent to long-term DAPT (12 months) in terms of efficacy and effectiveness for patients with ACS undergoing PCI 3, 6, 5
• Extended DAPT (>12 months) may reduce stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates, but increases bleeding risk 3, 4, 5
• Individualized approach is needed, taking into account the competing risks of bleeding and ischemic events 4, 5

Patient-Specific Considerations

Patient-specific considerations, such as bleeding risk, play a crucial role in determining the duration and type of DAPT therapy:

• Patients with high bleeding risk may benefit from abbreviated DAPT strategies 6
• Patients with diabetes may benefit from ticagrelor and aspirin therapy 3
• Patients with atrial fibrillation require individualized assessment of bleeding risk and antiplatelet therapy duration 3