What is the recommended duration and regimen for dual antiplatelet therapy (DAPT) in patients with coronary stent placement or acute coronary syndrome?

Dual Antiplatelet Therapy for Coronary Stent Placement and Acute Coronary Syndrome

For patients with coronary stent placement or acute coronary syndrome, dual antiplatelet therapy (DAPT) should be administered for 12 months as the standard duration, with specific P2Y12 inhibitor selection and duration modifications based on clinical presentation and bleeding risk. 1

P2Y12 Inhibitor Selection

• For patients with acute coronary syndrome (ACS), ticagrelor (180 mg loading dose, 90 mg twice daily) plus low-dose aspirin is recommended as first-line therapy regardless of initial treatment strategy 1, 2
• Prasugrel (60 mg loading dose, 10 mg daily) plus aspirin is an alternative for P2Y12 inhibitor-naïve patients with ACS undergoing PCI, unless high bleeding risk or contraindications exist 2
• Clopidogrel (75 mg daily) plus aspirin is recommended when ticagrelor or prasugrel are contraindicated, such as in patients with prior intracranial bleeding or requiring oral anticoagulation 1, 2
• For stable coronary artery disease patients undergoing PCI, clopidogrel is the default P2Y12 inhibitor 1

Duration of DAPT Based on Clinical Scenario

Acute Coronary Syndrome Patients:

• Standard duration: 12 months of DAPT regardless of treatment strategy (medical therapy, PCI, or CABG) 1
• High bleeding risk: Consider shortening to 6 months 1
• Low bleeding risk with good tolerance: May consider extending beyond 12 months 1

Stable CAD with PCI and Stent Placement:

• Drug-eluting stents: 1-6 months depending on bleeding risk 1
• Bare-metal stents: Minimum 1 month 1
• For all stents: Consider continuing for 12 months if low bleeding risk 1

Special Considerations

Patients Requiring Oral Anticoagulation:

• Triple therapy (OAC + DAPT) should be limited to 1 month, with extension up to 6 months only in patients at high ischemic risk 1
• After triple therapy, continue dual therapy with OAC plus a single antiplatelet agent (preferably clopidogrel) up to 12 months 1
• Use clopidogrel as the P2Y12 inhibitor; ticagrelor and prasugrel are not recommended in triple therapy 1

Bleeding Risk Mitigation:

• Use radial over femoral access for coronary procedures 2
• Maintain low-dose aspirin (75-100 mg daily) 1, 2
• Prescribe proton pump inhibitors routinely with DAPT 2
• Consider bleeding risk scores (e.g., PRECISE-DAPT) for duration decisions 3

Perioperative Management:

• For elective non-cardiac surgery, consider delaying surgery until completion of minimum required DAPT duration 1
• If surgery cannot be delayed, maintain aspirin perioperatively if bleeding risk allows 2
• Never discontinue DAPT within the first month after stent placement 1, 2

Common Pitfalls to Avoid

• Prematurely discontinuing DAPT, especially within the first month after stent placement 2, 4
• Not switching from clopidogrel to ticagrelor in ACS patients when indicated 2
• Using prasugrel in patients with prior stroke or TIA (contraindicated) 2
• Not prescribing a PPI with DAPT to reduce gastrointestinal bleeding risk 2
• Using a one-size-fits-all approach rather than considering both ischemic and bleeding risks 5, 3

Recent Evidence

Recent meta-analyses suggest that shorter DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) may be associated with decreased net adverse clinical events and bleeding without differences in ischemic outcomes compared to 12-month DAPT 6. This approach may be particularly beneficial for patients with high bleeding risk.