What is the recommended dual antiplatelet therapy (DAPT) regimen for a patient with drug-eluting stent (DES) placement?

Recommended Dual Antiplatelet Therapy (DAPT) Regimen for Patients with Drug-Eluting Stent (DES) Placement

For patients with drug-eluting stent (DES) placement, dual antiplatelet therapy with aspirin 81 mg daily plus a P2Y12 inhibitor should be given for at least 12 months after stent implantation in patients with acute coronary syndrome (ACS), and for at least 6 months in patients with stable ischemic heart disease (SIHD). 1

DAPT Duration Based on Clinical Presentation

Acute Coronary Syndrome (ACS)

• P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) plus aspirin should be continued for at least 12 months after DES implantation 1
• Daily aspirin dose should be 81 mg (range 75-100 mg) 1
• In ACS patients, ticagrelor is reasonable to use in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 1
• For ACS patients without high bleeding risk or history of stroke/TIA, prasugrel is reasonable to choose over clopidogrel 1
• Continuation of DAPT beyond 12 months may be reasonable in patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk 1

Stable Ischemic Heart Disease (SIHD)

• P2Y12 inhibitor (clopidogrel) should be given for at least 6 months after DES implantation 1
• Daily aspirin dose should be 81 mg (range 75-100 mg) 1
• Continuation of DAPT beyond 6 months may be reasonable in patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk 1

P2Y12 Inhibitor Selection

For ACS Patients

• Ticagrelor: Preferred over clopidogrel (Class IIa recommendation) 1
• Prasugrel: Reasonable over clopidogrel in patients without high bleeding risk or history of stroke/TIA (Class IIa recommendation) 1
• Clopidogrel: Alternative when ticagrelor or prasugrel cannot be used 1

For SIHD Patients

• Clopidogrel is the P2Y12 inhibitor of choice 1

Special Considerations

High Bleeding Risk Patients

• In ACS patients with DES who develop high bleeding risk (e.g., need for oral anticoagulant therapy) or significant overt bleeding, discontinuation of P2Y12 inhibitor therapy after 6 months may be reasonable 1
• In SIHD patients with DES who develop high bleeding risk, discontinuation of P2Y12 inhibitor therapy after 3 months may be reasonable 1

Contraindications

• Prasugrel should not be administered to patients with prior history of stroke or TIA 1, 2
• Patients with high bleeding risk (recent trauma, surgery, active peptic ulcer disease, severe hepatic impairment) require careful consideration of DAPT duration 2

After DAPT Completion

• After the recommended DAPT duration, patients should continue on single antiplatelet therapy (typically aspirin) indefinitely 1

Common Pitfalls and Caveats

• Premature discontinuation of DAPT increases risk of stent thrombosis, myocardial infarction, and death 2
• Lapses in therapy should be avoided; if temporary discontinuation is necessary due to surgical procedures, DAPT should be restarted as soon as possible 2
• For patients requiring CABG surgery, P2Y12 inhibitors should be discontinued prior to surgery (clopidogrel and ticagrelor: 5 days; prasugrel: 7 days) but resumed postoperatively to complete the recommended DAPT duration 1
• Triple therapy (DAPT plus oral anticoagulant) significantly increases bleeding risk and should be kept as short as possible in patients requiring anticoagulation 1, 3

The guidelines have evolved toward more personalized DAPT duration based on the balance between ischemic and bleeding risks. While 12 months remains the standard recommendation for ACS patients and 6 months for SIHD patients with DES placement, the duration can be shortened in patients with high bleeding risk or extended in those with high thrombotic risk and low bleeding risk 1, 4.