What are the guidelines for dual antiplatelet therapy (DAPT)?

From the Guidelines

Dual antiplatelet therapy (DAPT) is recommended for patients with acute coronary syndrome (ACS) for at least 12 months, with ticagrelor preferred over clopidogrel unless the bleeding risk outweighs the potential ischemic benefit 1. The standard regimen for DAPT includes aspirin 81mg daily indefinitely plus a P2Y12 inhibitor such as clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily. Some key points to consider when prescribing DAPT include:

• Duration of therapy: 12 months is standard after ACS, while 6 months is typical after elective PCI with drug-eluting stents 1.
• Choice of P2Y12 inhibitor: ticagrelor is preferred over clopidogrel for patients with ACS, unless the bleeding risk outweighs the potential ischemic benefit 1.
• Bleeding risk: patients at high bleeding risk may receive shorter durations of DAPT (3-6 months), while those at high ischemic risk and low bleeding risk may benefit from extended therapy beyond 12 months 1.
• Specific patient populations: patients with prior MI at high ischemic risk may benefit from extended DAPT therapy beyond 12 months, while those with stable coronary disease may be treated with clopidogrel 1. It's also important to consider the patient's individual risk factors and clinical scenario when making decisions about DAPT therapy, as outlined in the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization 1.

From the FDA Drug Label

2.1 Acute Coronary Syndrome 7.7 Other Antiplatelet Agents

The guidelines for dual antiplatelet therapy (DAPT) are not explicitly stated in the provided drug label. However, it can be inferred that DAPT may be considered in certain cases, such as Acute Coronary Syndrome, where the label mentions the use of clopidogrel in this context.

• The label does mention the use of other antiplatelet agents but does not provide specific guidelines for DAPT.
• It is essential to consider the potential risks and benefits of DAPT, including the general risk of bleeding 2. However, without direct information, no conclusion can be drawn regarding the specific guidelines for DAPT.

From the Research

Guidelines for Dual Antiplatelet Therapy (DAPT)

The guidelines for DAPT vary depending on the patient's condition and the clinical scenario.

• For patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting, short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT 3.
• Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk 3, 4.
• Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death 3.
• The optimal duration of DAPT after carotid artery stenting is uncertain 3.
• For patients with acute coronary syndrome, 12-month DAPT remains the only class-I DAPT recommendation despite the lack of prospectively established evidence, leading to unnecessary and potentially harmful overtreatment in many patients 5.
• Short-term DAPT (≤3 months or 6 months) did not increase ischemic outcomes compared to long-term DAPT (12 months and >12 months) in patients with acute coronary syndrome 6.

Patient-Specific Considerations

• The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes 3.
• Bleeding risk assessment has emerged as a treatment modifier for maximizing the net clinical benefit of DAPT, due to excessive bleeding and no clear benefit of prolonged treatment regimens in high bleeding risk patients 5.
• Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk 3.
• Antiplatelet therapy duration in peripheral artery disease depends on the scenario, and adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively 3.