What is the recommended duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI)?

From the Guidelines

Dual antiplatelet therapy (DAPT) is recommended for at least 12 months after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS), as stated in the 2016 ACC/AHA guideline focused update 1. The standard regimen consists of aspirin (81-100 mg daily indefinitely) plus a P2Y12 inhibitor such as clopidogrel (75 mg daily), ticagrelor (90 mg twice daily), or prasugrel (10 mg daily).

• For patients with bare metal stents or drug-eluting stents placed during ACS, DAPT is generally recommended for 12 months.
• For elective PCI with drug-eluting stents, DAPT may be shortened to 6 months in patients with high bleeding risk or extended beyond 12 months in those with high ischemic risk and low bleeding risk. The 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease also supports an individualized approach based on ischemic vs. bleeding risk assessment 1. Key considerations include:
• Stent type: The need for a short DAPT regimen should no longer justify the use of bare metal stents instead of newer-generation drug-eluting stents.
• Indication for PCI: ACS patients have a default DAPT duration of 12 months, while stable CAD patients treated with PCI may have a shorter DAPT duration of 1-6 months depending on bleeding risk.
• Comorbidities and bleeding history: Patients with high bleeding risk may require a shorter DAPT duration, while those with high ischemic risk and low bleeding risk may benefit from extended DAPT. Regular reassessment of the risk-benefit balance is essential throughout the treatment period to optimize outcomes and minimize complications, as recommended by both the 2016 ACC/AHA guideline focused update 1 and the 2017 ESC focused update 1.

From the Research

Duration of Dual Antiplatelet Therapy (DAPT) After Percutaneous Coronary Intervention (PCI)

The recommended duration of DAPT after PCI is a topic of ongoing debate and research. According to recent studies, the optimal duration of DAPT may vary depending on individual patient risk factors and clinical presentation.

Current Guidelines and Recommendations

• The present guidelines recommend DAPT for 6 to 12 months after PCI, with recent trials assessing the safety and efficacy of shortening DAPT duration to ≤3 months 2.
• A highly individualized approach is being practiced, taking into account the patient's individual bleeding and ischemic risk 3.
• Prolonged DAPT (>12 months) is currently recommended for patients post myocardial infarction with a low bleeding risk, at high ischemic risk due to coronary triple vessel disease, following a high-risk coronary intervention with an unsatisfactory result or a personal history of prior stent thrombosis 3.

Shortened DAPT Duration

• Short DAPT for ≤3 months followed by P2Y12i monotherapy (particularly, ticagrelor) was associated with decreased net adverse clinical events and bleeding without differences in other outcomes 2.
• Reduced-duration DAPT of 3-6 months is being recommended for most patients 3.
• In patients with a high bleeding risk, a DAPT treatment period of 4 weeks may be sufficient with a markedly reduced rate of bleeding and without evidence for more ischemic events 3.

Comparison of DAPT Duration Strategies

• A meta-analysis comparing short-term (≤3 months) DAPT followed by P2Y12 monotherapy versus standard DAPT in patients after PCI found similar rates of major bleeding, mortality, and stroke 4.
• Another study found that clopidogrel was associated with reductions in major adverse cardiac events and stroke when compared with aspirin after completing DAPT 5.