What are the indications for Dual Antiplatelet Therapy (DAPT)?

Indications for Dual Antiplatelet Therapy (DAPT)

Dual antiplatelet therapy is primarily indicated for patients with acute coronary syndrome (ACS) and those undergoing percutaneous coronary intervention (PCI), with duration varying based on clinical presentation, bleeding risk, and type of intervention. 1

Primary Indications for DAPT

Acute Coronary Syndrome (ACS)

• Default DAPT duration is 12 months for all ACS patients, regardless of management strategy (medical therapy, PCI, or CABG) 1
• For high bleeding risk patients, a shortened 6-month therapy should be considered 1
• For patients who tolerate DAPT without bleeding complications, therapy >12 months may be considered 1
• Preferred P2Y12 inhibitors in ACS:
  • Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all ACS patients regardless of initial treatment strategy 1
  • Prasugrel (60 mg loading dose, 10 mg daily) is recommended for P2Y12 inhibitor-naïve ACS patients undergoing PCI 1
  • Clopidogrel is reserved for patients with contraindications to ticagrelor or prasugrel 1

Stable Coronary Artery Disease (CAD) with PCI

• DAPT duration ranges from 1-6 months depending on bleeding risk 1
• Longer DAPT may be considered when ischemic risk outweighs bleeding risk 1
• Clopidogrel is the default P2Y12 inhibitor for stable CAD patients treated with PCI 1
• DAPT duration should be individualized based on ischemic vs. bleeding risk assessment rather than stent type 1

Special Populations and Considerations

Patients Requiring Oral Anticoagulation

• Addition of DAPT to oral anticoagulation increases bleeding risk 2-3 fold 1
• Triple therapy (DAPT plus anticoagulation) should be limited to a maximum of 6 months or omitted after hospital discharge 1
• Ticagrelor and prasugrel are not recommended in patients requiring triple therapy 1

Prior Stent Thrombosis

• Patients with prior stent thrombosis, especially without correctable causes, should receive prolonged DAPT 1
• Prolonged DAPT may also be considered in patients with peripheral arterial disease or who have undergone complex PCI 1

Patients Undergoing Non-cardiac Surgery

• For scheduled surgery requiring P2Y12 inhibitor discontinuation, consider waiting at least 1 month after stent implantation 1
• If aspirin can be maintained throughout the perioperative period, this approach is preferred 1
• For surgery within 1 month of stent placement where both antiplatelet agents must be discontinued, consider bridging with cangrelor, tirofiban, or eptifibatide 1

Recent Evidence on DAPT Duration

• Recent research suggests short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and bleeding without increasing ischemic events 2
• In patients with high bleeding risk, shorter DAPT durations (3-6 months) provide a good compromise between hemorrhagic risk and ischemic recurrences 3

Common Pitfalls and Caveats

• Discontinuing both antiplatelet agents shortly after PCI should only be considered in life-threatening bleeding situations where the source cannot be treated 1
• The need for short DAPT should not justify using bare-metal stents instead of newer-generation drug-eluting stents 1
• Gender and diabetes status do not affect DAPT recommendations - similar type and duration are recommended for both male and female patients, and for patients with and without diabetes 1
• Always reassess type, dose, and duration of DAPT when patients experience actionable bleeding complications 1