What is the recommended duration of Dual Antiplatelet Therapy (DAPT) for patients after Percutaneous Coronary Intervention (PCI) with stent placement and Coronary Artery Bypass Grafting (CABG)?

Duration of Dual Antiplatelet Therapy After PCI, Stent Placement, and CABG

For patients who have undergone PCI with stent placement, the recommended DAPT duration is 6 months for drug-eluting stents in stable coronary artery disease, while patients with ACS should receive 12 months of DAPT regardless of stent type. For CABG patients, DAPT should be continued for 12 months after ACS or to improve vein graft patency. 1

DAPT Duration Based on Clinical Scenario

PCI with Stent Placement

Stable Coronary Artery Disease

• Drug-eluting stents (DES): 6 months of DAPT (Class I, Level B) 1, 2
• Bare-metal stents (BMS): 1 month of DAPT (Class I, Level A) 1, 2
• Drug-coated balloons: 6 months of DAPT (Class IIa, Level B) 1

Acute Coronary Syndrome

• All stent types: 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) 2

After CABG

• 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
• Stable CAD patients after CABG: 12 months of DAPT with clopidogrel initiated early postoperatively may be reasonable to improve vein graft patency (Class IIb, Level B-NR) 1

Risk-Based Adjustments to DAPT Duration

Extended DAPT

• For patients who have tolerated DAPT without bleeding complications and have low bleeding risk but high thrombotic risk, DAPT may be extended beyond the standard duration up to 30 months (Class IIb, Level A) 1, 2
• Extended DAPT (18-48 months) decreases myocardial infarction (OR: 0.67) and stent thrombosis (OR: 0.45) but increases major hemorrhage (OR: 1.58) 1

Shortened DAPT

• High bleeding risk patients with stable CAD and DES:
  • 3 months of DAPT (Class IIa, Level B) 1, 2
  • 1 month of DAPT in extreme cases (Class IIb, Level C) 1, 2
• High bleeding risk patients with ACS:
  • 6 months of DAPT may be considered (Class IIb, Level C) 2

Important Considerations

Aspirin Dosing

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

Newer Evidence on Short DAPT

• Recent meta-analysis shows that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and bleeding without increasing ischemic events compared to 12-month DAPT 3

Stent Technology Considerations

• Newer-generation DES have lower rates of stent thrombosis, which has influenced the trend toward shorter DAPT durations 2
• For bioabsorbable polymer stents and bioabsorbable stents, DAPT was continued for 6-12 months in studies, but specific recommendations are limited 1

Pitfalls and Caveats

1. Premature DAPT discontinuation: Avoid early discontinuation as it significantly increases the risk of stent thrombosis, particularly in the first months after PCI 2

2. Balancing risks: Always weigh ischemic benefits against bleeding risks when determining DAPT duration 1

3. Special populations: Patients on oral anticoagulation require special consideration for DAPT duration due to increased bleeding risk 1

4. Switching between P2Y12 inhibitors: When switching is necessary due to side effects or intolerance, follow specific protocols to maintain adequate platelet inhibition 1

5. Elective surgery: If non-cardiac surgery is needed, consider that surgery should be delayed at least 1 month after stent placement regardless of stent type, and preferably 6 months in case of recent MI 1