What is the duration of dual antiplatelet therapy (DAPT) post percutaneous coronary intervention (PCI) with drug-eluting stent (DES)?

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DS

Dainyal Siddiqui, MD

Internal Medicine

MJ

Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: March 10, 2025 • View editorial policy

From the Guidelines

The recommended duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is at least 6 months for patients with stable ischemic heart disease (SIHD) and at least 12 months for patients with acute coronary syndrome (ACS), as supported by the most recent guidelines 1.

Key Considerations

  • DAPT typically consists of aspirin 81mg daily indefinitely plus a P2Y12 inhibitor such as clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily.
  • The duration of DAPT should be personalized based on individual risk factors, including ischemic and bleeding risks.
  • For patients with high bleeding risk, shorter durations (1-3 months) may be appropriate, while extended therapy beyond 12 months may benefit those with high ischemic risk and low bleeding risk.

Rationale

  • The 2018 ESC/EACTS guidelines on myocardial revascularization recommend DAPT for 12 months after PCI for NSTE-ACS, irrespective of the stent type 1.
  • The 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease also supports a minimum of 6-12 months of DAPT, depending on the clinical setting 2, 3.
  • The benefit/risk ratio of prolonged DAPT should be carefully assessed, taking into account the individual patient's risk factors and preferences.

Important Factors

  • The type of stent used, with newer-generation stents having a lower risk of stent thrombosis.
  • The patient's individual risk factors, including history of myocardial infarction, diabetes, and renal impairment.
  • The presence of high bleeding risk, such as oral anticoagulation or significant overt bleeding.

From the Research

Duration of Dual Antiplatelet Therapy (DAPT) Post Percutaneous Coronary Intervention (PCI) with Drug-Eluting Stent (DES)

  • The optimal duration of DAPT after PCI with DES remains uncertain, with guidelines recommending DAPT for 6 to 12 months 4, 5, 6.
  • Recent trials have assessed the safety and efficacy of shortening DAPT duration to ≤3 months, with some studies suggesting that short DAPT followed by P2Y12 inhibitor monotherapy may be associated with decreased net adverse clinical events (NACEs) and bleeding without differences in other outcomes 4, 7, 8.
  • A meta-analysis of randomized controlled trials found that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy was comparable to 12 months of DAPT with respect to major adverse cardiovascular events (MACE) and thrombotic events, with lower rates of major bleeding events 7.
  • Another study found that extended-term DAPT (>12 months) was associated with a reduced risk of myocardial infarction, but at the expense of more bleeding events, while short-term DAPT followed by P2Y12 inhibitor monotherapy reduced major bleeding without a significant increase in ischemic events 8.
  • The choice of optimal DAPT regimen and duration for patients with coronary artery disease requires a tailored approach based on the patient's clinical presentation, baseline risk profile, and management strategy 5, 6.

Key Findings

  • Short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy may be a favorable option for patients with acute coronary syndrome (ACS) or chronic coronary syndrome after PCI with DES 4, 7.
  • Extended-term DAPT (>12 months) may be associated with a reduced risk of myocardial infarction, but at the expense of more bleeding events 8.
  • The optimal duration of DAPT after PCI with DES should be individualized based on the patient's risk profile and clinical presentation 5, 6.

Study Results

  • A study of 42,770 patients found that short DAPT significantly reduced NACEs, major bleeding, and any bleeding at 12 months compared with 1-year DAPT 4.
  • A meta-analysis of 20,706 patients found that short DAPT followed by P2Y12 inhibitor monotherapy was comparable to 12 months of DAPT with respect to MACE and thrombotic events, with lower rates of major bleeding events 7.
  • A network meta-analysis of 79,073 patients found that extended-term DAPT was associated with a reduced risk of myocardial infarction, but at the expense of more bleeding events, while short-term DAPT followed by P2Y12 inhibitor monotherapy reduced major bleeding without a significant increase in ischemic events 8.

References

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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