From the Guidelines
For patients with NSTEMI who have undergone PCI with drug-eluting stent placement and have low bleeding risk, the recommended DAPT duration is at least 12 months. The standard regimen consists of aspirin 81 mg daily indefinitely plus a P2Y12 inhibitor (preferably ticagrelor 90 mg twice daily or prasugrel 10 mg daily) for 12 months, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent st-segment elevation 1.
Key Considerations
- The P2Y12 inhibitors prevent ADP-mediated platelet activation while aspirin blocks thromboxane A2 production, reducing the risk of stent thrombosis and recurrent ischemic events by inhibiting platelet aggregation through complementary mechanisms.
- Patients should be monitored for bleeding complications throughout DAPT treatment, and medication adherence should be emphasized at each follow-up visit.
- For selected patients with very low bleeding risk and high ischemic risk, DAPT duration may be extended beyond 12 months after careful consideration of individual risk factors, as suggested by the 2020 ESC guidelines 1.
Bleeding Risk Assessment
- The decision to extend DAPT duration should be based on a careful assessment of the patient's bleeding risk, using tools such as the PRECISE-DAPT or ARC-HBR criteria, as mentioned in the 2020 ESC guidelines 1.
- Patients with a high risk of bleeding may require a shorter duration of DAPT, while those with a low risk of bleeding may benefit from extended DAPT, as recommended by the 2020 ESC guidelines 1.
Comparison with Other Guidelines
- The 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease also recommends DAPT for at least 12 months in patients with ACS treated with PCI, but does not provide specific guidance on extending DAPT beyond 12 months 1.
- However, the 2020 ESC guidelines provide more up-to-date and specific recommendations on DAPT duration, making them the preferred reference for clinical decision-making.
From the Research
Dual Antiplatelet Therapy Duration for NSTEMI Patients
- The recommended duration of dual antiplatelet therapy (DAPT) for non-ST-elevation myocardial infarction (NSTEMI) patients post percutaneous coronary intervention (PCI) with a drug-eluting stent, who have a low risk of bleeding, is not explicitly stated in the provided studies.
- However, according to 2, if the bleeding risk is low, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established.
- A study by 3 found that 6 months of DAPT was non-inferior to 12 months of DAPT in patients with event-free ST-elevation myocardial infarction (STEMI) at 6 months after primary PCI with second-generation drug-eluting stents.
- Another study by 4 compared clopidogrel with aspirin following completion of DAPT after PCI and found that clopidogrel was associated with reductions in major adverse cardiac events (MACE) and stroke.
- The NEOMINDSET Trial, described in 5, aims to compare P2Y12 inhibitor monotherapy versus DAPT in patients with acute coronary syndromes undergoing coronary stenting, but the results are not yet available.
- The OPTICA study, described in 6, evaluated the feasibility and safety of ticagrelor or prasugrel monotherapy directly following PCI in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), but it did not provide information on the optimal duration of DAPT.