What are the preferred guidelines for dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI)?

From the Guidelines

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) should be individualized based on the patient's ischemic and bleeding risk profile, with the most recent guidelines recommending DAPT for at least 1 year in patients with acute coronary syndrome (ACS) and 1-6 months in stable coronary artery disease (CAD) patients, depending on the bleeding risk 1. The choice of P2Y12 inhibitor depends on patient factors, with prasugrel and ticagrelor providing stronger platelet inhibition but carrying higher bleeding risk, while clopidogrel has lower bleeding risk but variable antiplatelet effect.

• For patients receiving drug-eluting stents (DES), DAPT is generally recommended for 6-12 months, with aspirin 81 mg daily plus either clopidogrel 75 mg daily, ticagrelor 90 mg twice daily, or prasugrel 10 mg daily.
• For bare metal stents (BMS), a shorter DAPT duration of at least 1 month is acceptable.
• High bleeding risk patients may receive shortened DAPT (3-6 months), while those at high ischemic risk and low bleeding risk may benefit from extended therapy beyond 12 months.
• Aspirin should be continued indefinitely after completing DAPT. The most recent guidelines from 2025 recommend that DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year to reduce major adverse cardiac events (MACE) in patients with ACS who are not at high bleeding risk 1. In patients at high risk of gastrointestinal bleeding, a proton pump inhibitor (PPI) is recommended in combination with DAPT to reduce the risk of bleeding 1. Transition to ticagrelor monotherapy ≥1 month post-PCI may be considered in patients who have tolerated DAPT with ticagrelor to reduce bleeding risk 1. De-escalation of DAPT (switching from ticagrelor or prasugrel to clopidogrel) after 1 month may be reasonable to reduce bleeding risk in patients at high bleeding risk 1. In patients undergoing PCI, the duration of DAPT should be guided by an individualized approach based on ischemic vs. bleeding risk assessment, rather than the stent type 1. The use of a bleeding mitigation strategy, including access site selection, modulation of modifiable risk factors for bleeding, low-dose aspirin, and low-dose P2Y12 inhibitor, is recommended to mitigate the risk of bleeding complications while the patient is on DAPT 1.

From the FDA Drug Label

Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) Initiate prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The preferred guidelines for dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) include:

• Initiating prasugrel tablets treatment as a single 60 mg oral loading dose and then continuing at 10 mg orally once daily
• Taking aspirin (75 mg to 325 mg) daily in combination with prasugrel tablets
• Considering a lower maintenance dose of 5 mg in patients weighing less than 60 kg due to increased exposure to the active metabolite and risk of bleeding 2

From the Research

Dual Antiplatelet Therapy Guidelines

The guidelines for dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) are as follows:

• For patients with stable ischemic heart disease, at least six months of DAPT following a drug-eluting stent and one month following a bare metal stent should be implemented 3.
• In patients with acute coronary syndrome, including non-ST elevation and ST elevation myocardial infarction, it is recommended to extend DAPT treatment to one year in both drug-eluting stent and bare metal stent groups 3.
• A short-term DAPT followed by extended P2Y12 inhibitor monotherapy might be appropriate for patients with both high ischemic and bleeding risks 4.

Aspirin-Free Antiplatelet Strategies

Aspirin-free antiplatelet strategies after PCI have been investigated in several trials:

• P2Y12 inhibitor monotherapy after a short course of DAPT has been shown to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischemic events compared with continued DAPT 5.
• The effects of P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies 5.

Platelet Function Testing

Platelet function testing has been shown to be a valuable tool to assess the pharmacodynamic efficacy of antiplatelet drugs:

• Several assays are available to measure platelet reactivity, and platelet function testing has important prognostic implications 6.
• The use of platelet function testing has been advocated to create personalized antiplatelet therapy, but major clinical trials have failed to demonstrate a benefit of such a strategy in improving clinical outcomes 6.

Optimizing Platelet P2Y12 Inhibition

Optimizing platelet P2Y12 inhibition for patients undergoing PCI is crucial:

• A 300-mg loading dose of clopidogrel must be administered at least 15 h prior to PCI to achieve a significant reduction in peri-PCI thrombotic events 7.
• Prasugrel, AZD6140, and cangrelor are platelet P2Y12 receptor antagonists that offer faster acting inhibition of adenosine diphosphate (ADP)--induced platelet aggregation 7.