What is the recommended duration of dual antiplatelet therapy (DAPT) for patients with coronary artery disease (CAD) who have received stents?

Duration of Dual Antiplatelet Therapy (DAPT) for CAD with Stents

The recommended duration of DAPT for patients with coronary artery disease who have received stents should be individualized based on clinical presentation, with 12 months being the standard duration for ACS patients and 1-6 months for stable CAD patients with newer-generation drug-eluting stents. 1

DAPT Duration Based on Clinical Presentation

Acute Coronary Syndrome (ACS) Patients

• Default DAPT duration: 12 months regardless of revascularization strategy (medical therapy, PCI, or CABG) 1
• Modifications based on bleeding risk:
  • High bleeding risk: Consider 6-month therapy 1
  • Low bleeding risk with good tolerance: Consider extending beyond 12 months 1

Stable CAD Patients with PCI

• DAPT duration: 1-6 months depending on bleeding risk 1
• For patients with low bleeding risk but high ischemic risk: Consider longer DAPT duration 1
• For high bleeding risk patients: Consider shorter duration (3 months or even 1 month) 1

P2Y12 Inhibitor Selection

• Stable CAD with PCI: Clopidogrel is the default P2Y12 inhibitor 1
• ACS patients: Ticagrelor or prasugrel recommended unless contraindicated 1
• Patients requiring oral anticoagulation: Clopidogrel is preferred (ticagrelor or prasugrel not recommended) 1

Risk Assessment for DAPT Duration

The optimal duration should be determined by balancing:

1. Ischemic risk factors:

   • Prior MI or ACS presentation
   • Multiple stents/complex PCI (≥3 stents, ≥3 lesions treated, bifurcation with 2 stents, total stent length >60mm)
   • Chronic total occlusion intervention
   • Diabetes mellitus
   • Left ventricular dysfunction

2. Bleeding risk factors:

   • Advanced age
   • Oral anticoagulation requirement
   • Prior major bleeding
   • Anemia
   • Renal dysfunction

Special Considerations

Patients Requiring Oral Anticoagulation

• Triple therapy (DAPT + anticoagulant) duration should be limited to a maximum of 6 months 1
• Consider omitting triple therapy after hospital discharge in selected patients 1
• Use clopidogrel as the P2Y12 inhibitor (avoid ticagrelor/prasugrel) 1

Elective Non-cardiac Surgery

• Consider delaying elective surgery requiring P2Y12 inhibitor discontinuation for at least 1 month after stent placement 1
• If surgery cannot be delayed, aspirin should be maintained throughout the perioperative period if possible 1

Common Pitfalls to Avoid

1. Stent type misconception: The need for a specific DAPT duration should no longer be based on stent type (BMS vs. DES) but rather on patient-specific ischemic and bleeding risks 1

2. Overlooking bleeding risk: Always implement bleeding mitigation strategies including:

   • Low-dose aspirin (75-100mg)
   • Appropriate P2Y12 inhibitor dosing
   • Proton pump inhibitor use when indicated 1

3. One-size-fits-all approach: Recognize that DAPT duration should be tailored based on the balance between thrombotic and bleeding risks rather than applying a fixed duration for all patients 1

4. Premature discontinuation: Stopping DAPT too early (especially within first month) significantly increases stent thrombosis risk 1

By carefully assessing individual patient risk factors and following these guidelines, clinicians can optimize the duration of DAPT therapy to maximize benefit while minimizing bleeding complications.