What are the current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the duration of dual antiplatelet therapy (DAPT) post percutaneous coronary intervention (PCI)?

ACC/AHA Guidelines for Duration of DAPT Post PCI

The current ACC/AHA guidelines recommend a standard 12-month DAPT duration for ACS patients after PCI, while stable CAD patients should receive 6 months of DAPT after drug-eluting stent implantation or 1 month after bare-metal stent implantation, with adjustments based on bleeding and thrombotic risk. 1

Standard DAPT Duration Recommendations

For Stable Coronary Artery Disease (SCAD)

• Drug-eluting stents (DES): 6 months of DAPT (Class I, Level B) 1
• Bare-metal stents (BMS): 1 month of DAPT (Class I, Level A) 1
• Drug-coated balloons (DCB): 6 months of DAPT (Class IIa, Level B) 1

For Acute Coronary Syndrome (ACS)

• All stent types: At least 12 months of DAPT (Class I, Level B) 1
• P2Y12 inhibitor preference: Ticagrelor or prasugrel preferred over clopidogrel if no contraindications exist (Class IIa, Level B) 1

Risk-Based Adjustments to DAPT Duration

Extended DAPT Duration

• For patients who have tolerated DAPT without bleeding complications and have low bleeding risk:
  • SCAD patients: May consider extending beyond 6 months up to 30 months (Class IIb, Level A) 1
  • ACS patients: May consider extending beyond 12 months (Class IIb, Level A) 1

Shortened DAPT Duration

• For high bleeding risk patients:
  • SCAD patients with DES: May shorten to 3 months (Class IIa, Level B) or even 1 month (Class IIb, Level C) 1
  • ACS patients: May shorten to 6 months if high bleeding risk or significant overt bleeding (Class IIb, Level C) 1

Special Considerations

CABG Patients

• For ACS patients who undergo CABG: P2Y12 inhibitor therapy should be resumed post-CABG to complete 12 months of DAPT (Class I, Level C-LD) 1
• For stable CAD patients: 12-month DAPT with clopidogrel after CABG may improve vein graft patency (Class IIb, Level B-NR) 1

Aspirin Dosing

• Low-dose aspirin (75-100 mg daily) is recommended for all patients on DAPT (Class I, Level B-NR) 1, 2

Practical Algorithm for DAPT Duration Decision-Making

1. Determine clinical presentation:

   • ACS → Standard 12 months DAPT
   • SCAD → Standard 6 months DAPT for DES, 1 month for BMS

2. Assess bleeding risk factors:

   • Age ≥75 years
   • Oral anticoagulation requirement
   • History of bleeding
   • Thrombocytopenia
   • Active cancer
   • Chronic kidney disease

3. Adjust duration based on risk assessment:

   • High bleeding risk + SCAD → Shorten to 1-3 months
   • High bleeding risk + ACS → Consider 6 months
   • Low bleeding risk + high thrombotic risk → Consider extending beyond standard duration

Common Pitfalls and Caveats

• Avoid premature DAPT discontinuation: This increases the risk of stent thrombosis, particularly in the first months after PCI 1
• Balance ischemic and bleeding risks: Recent guidelines have shifted toward shorter standard DAPT regimens than previously recommended, with flexibility based on individual risk factors 1
• Consider P2Y12 inhibitor monotherapy: Recent evidence suggests that short DAPT followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) may reduce bleeding events without increasing ischemic events 3, 4
• Recognize the evolution of stent technology: Newer-generation DES have lower rates of stent thrombosis, which has influenced the trend toward shorter DAPT durations 1

The decision regarding DAPT duration should be made at the time of PCI and reassessed during follow-up visits, with careful consideration of both thrombotic and bleeding risks to optimize patient outcomes in terms of mortality, morbidity, and quality of life.