What is the recommended duration of DAPT for a young patient with low-risk bleeding, post-PCI with DES for NSTEMI and a GRACE score of 77?

From the Guidelines

For a young patient with low bleeding risk who has undergone percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement after a non-ST elevation myocardial infarction (NSTEMI) and has a low GRACE score of 77, the recommended duration of dual antiplatelet therapy (DAPT) is 12 months. The DAPT regimen should consist of aspirin 81 mg daily indefinitely plus a P2Y12 inhibitor such as ticagrelor 90 mg twice daily or clopidogrel 75 mg daily for the 12-month period, as supported by the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease 1. Ticagrelor is generally preferred over clopidogrel in acute coronary syndrome patients due to its superior efficacy in preventing recurrent cardiovascular events, as noted in the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1. After completing 12 months of DAPT, the patient should continue aspirin monotherapy indefinitely. This recommendation balances the need to prevent stent thrombosis and recurrent ischemic events while minimizing bleeding risk. The low GRACE score indicates lower mortality risk, but the presence of an acute coronary syndrome (NSTEMI) and DES placement necessitates adequate DAPT duration to prevent adverse cardiovascular outcomes. In select cases with very low ischemic risk and concerns about bleeding, DAPT duration could potentially be shortened to 6 months, but this would require individualized assessment and discussion with the patient, considering the latest guidelines and evidence from studies such as the comparison of ACC/AHA and ESC guidelines on dual antiplatelet therapy 1.

Some key points to consider in the management of DAPT include:

• The use of a DAPT score to assess the risk/benefit of prolonging DAPT, as recommended in the 2016 ACC/AHA update 1.
• The preference for ticagrelor or prasugrel over clopidogrel in ACS patients, unless contraindicated, as stated in the 2017 ESC update 1.
• The consideration of switching P2Y12 inhibitors in cases of side effects or drug intolerance, as discussed in the 2017 ESC update 1.
• The importance of proton pump inhibitors in patients on DAPT, especially those with a history of gastrointestinal bleeding or at increased risk, as recommended in both the 2016 ACC/AHA and 2017 ESC updates 1.

Overall, the management of DAPT in patients with coronary artery disease, including those with ACS and undergoing PCI with DES, requires careful consideration of the individual patient's risk factors, the type of stent used, and the latest evidence-based guidelines.

From the Research

Recommended Duration of DAPT

The recommended duration of Dual Antiplatelet Therapy (DAPT) for a young patient with low-risk bleeding, post-PCI with Drug-Eluting Stent (DES) for Non-ST-Elevation Myocardial Infarction (NSTEMI) and a Global Registry of Acute Coronary Events (GRACE) score of 77 is as follows:

• For patients with low-risk bleeding, prolonged DAPT may be considered, although the optimal duration of prolonged DAPT beyond 1 year is not well established 2
• Current guidelines recommend a duration of DAPT with aspirin and oral P2Y12 receptor inhibitors following PCI with second-generation DES of 6 months for most patients with stable coronary disease and of 12 months for most patients with acute coronary syndromes 3
• Recent studies suggest that long-term DAPT, compared with shorter DAPT, reduced ischemic events without a concomitant increase in clinically meaningful bleeding events in high-risk ACS patients undergoing PCI 4

Factors Influencing DAPT Duration

The following factors influence the duration of DAPT:

• Risk of bleeding: If bleeding risk is low, prolonged DAPT may be considered 2
• Risk of ischemic events: Patients with high-risk features, such as high GRACE score, may benefit from prolonged DAPT 4
• Type of stent used: Newer-generation DES may allow for shorter DAPT duration 3, 5

Patient-Specific Considerations

For a young patient with low-risk bleeding, post-PCI with DES for NSTEMI and a GRACE score of 77, the following considerations apply:

• The patient's low-risk bleeding profile suggests that prolonged DAPT may be considered 2
• The patient's high GRACE score indicates a higher risk of ischemic events, which may benefit from prolonged DAPT 4