Should elderly patients with Acute Coronary Syndrome (ACS) be on Dual Antiplatelet Therapy (DAPT) instead of monotherapy?

From the Guidelines

Elderly patients with Acute Coronary Syndrome (ACS) should generally receive Dual Antiplatelet Therapy (DAPT) rather than monotherapy, but with careful consideration of bleeding risk. The standard DAPT regimen consists of aspirin 81mg daily plus a P2Y12 inhibitor such as clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily (though prasugrel is often avoided in elderly patients due to higher bleeding risk) 1. For most elderly ACS patients who undergo percutaneous coronary intervention (PCI), DAPT should be continued for at least 6-12 months, with consideration for shorter durations (3-6 months) in those at high bleeding risk.

Key factors to consider when deciding on DAPT duration include:

• Ischemic risk
• Bleeding risk
• Frailty
• Comorbidities (especially renal impairment)
• Medication interactions
• Fall risk
• Prior bleeding history

Regular reassessment of bleeding risk is essential, and proton pump inhibitors should be considered for gastrointestinal protection 1. In very high bleeding risk elderly patients, a shorter DAPT duration followed by transition to single antiplatelet therapy may be appropriate after discussing risks and benefits with the patient. The most recent guidelines suggest that DAPT reduces the risk of early and late thrombotic events among patients with ACS, regardless of whether they are managed with an invasive strategy 1. However, prolonged exposure to DAPT results in excess bleeding, and identifying individuals most likely to realize a net clinical benefit or harm from prolonged DAPT is crucial.

The choice and duration of antithrombotic regimens largely depend on the delicate balance between each individual’s ischemic and bleeding risks 1. Ultimately, the decision to use DAPT in elderly patients with ACS should be made on a case-by-case basis, taking into account the patient's unique risk factors and medical history. As the most recent and highest quality study, the 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline provides the best evidence for guiding this decision 1.

From the FDA Drug Label

The effect of clopidogrel did not differ significantly in various prespecified subgroups as shown in Figure 6 The effect was also similar in non-prespecified subgroups including those based on infarct location, Killip class or prior MI history. The patient population was 28% women and 58% age ≥60 years (26% age ≥70 years).

The elderly patients with Acute Coronary Syndrome (ACS) should be on Dual Antiplatelet Therapy (DAPT) instead of monotherapy, as the benefits of clopidogrel were observed in the elderly population (58% age ≥60 years) in the COMMIT study 2.

• The study showed that clopidogrel significantly reduced the relative risk of death from any cause by 7% (p=0.029), and the relative risk of the combination of re-infarction, stroke or death by 9% (p=0.002) in patients with STEMI.
• The effect of clopidogrel did not differ significantly in various prespecified subgroups, including those based on age.
• However, it is essential to consider the individual patient's risk factors and medical history when making treatment decisions.

From the Research

Dual Antiplatelet Therapy (DAPT) in Elderly Patients with Acute Coronary Syndrome (ACS)

• Elderly patients with ACS may benefit from DAPT, which consists of aspirin and a P2Y12 inhibitor, to reduce cardiovascular event rates 3.
• The choice of DAPT should be tailored to the individual patient's risk of bleeding and myocardial ischemia, with consideration of factors such as age, weight, diabetes, and prior bleeding 3, 4.
• For elderly patients with a high bleeding risk, a shorter duration of DAPT (3-6 months) may be reasonable, while those with a low bleeding risk may benefit from prolonged DAPT 3, 5.
• Clopidogrel is considered a safe and effective alternative to ticagrelor in elderly patients with an increased bleeding risk 4, 5.
• De-escalation strategies, such as starting with DAPT that includes aspirin and low-dose prasugrel, then switching to DAPT with aspirin and clopidogrel, may be reasonable for elderly patients with a high thrombotic risk and bleeding risk 5.

Net Clinical Benefit of DAPT in Elderly Patients with ACS

• Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks 6.
• The net clinical benefit of DAPT, a composite of major adverse cardiovascular events and clinically relevant bleeding, should be considered when making treatment decisions for elderly patients with ACS 6.
• Further research is needed to confirm the findings of current studies and to determine the optimal DAPT strategy for elderly patients with ACS 6, 7.

Extended Use of DAPT in Older Adults with ACS

• Approximately one-third of patients aged 65 years or older with ACS receive extended DAPT beyond 1 year, similar to their younger counterparts 7.
• The severity of coronary disease, prior heart failure, left ventricle ejection fraction, and prior stent thrombosis are associated with extended DAPT in older adults with ACS 7.
• There is no significant correlation between high bleeding risk and DAPT duration in older adults with ACS, highlighting the need for individualized treatment decisions 7.