When to continue DAPT at 3-month re-evaluation after PCI with stent placement?

When to Continue DAPT at 3-Month Re-evaluation After PCI

Continue DAPT beyond 3 months if the patient has tolerated therapy without bleeding complications AND is not at high bleeding risk, particularly if they have high thrombotic risk features such as ACS presentation, complex stenting, prior stent thrombosis, or multiple comorbidities. 1

Decision Algorithm at 3-Month Assessment

Discontinue DAPT at 3 Months If:

• High bleeding risk patients who have remained event-free (no MI, repeat revascularization, stroke, or stent thrombosis) 1

  • High bleeding risk includes: age ≥75 years, oral anticoagulation requirement, thrombocytopenia, active cancer, recent GI bleeding, severe hepatic impairment, or moderate-to-severe renal impairment 1, 2
  • ESC guidelines give this a Class IIa recommendation (Level B) for stable CAD patients 1
  • ACC/AHA guidelines give this a Class IIb recommendation (Level C) for DES patients with high bleeding risk or significant overt bleeding 1

• Stable CAD patients with newer-generation DES who are not at high thrombotic risk and have tolerated DAPT without complications 1

  • Recent evidence supports 1-3 months DAPT reduces bleeding (RR 0.68) without increasing MI, stent thrombosis, or MACE 3, 4, 5

Continue DAPT Beyond 3 Months (to 6-12 Months) If:

• ACS presentation (NSTEMI, STEMI, or unstable angina) - continue to 12 months minimum 1

  • This is a Class I recommendation (Level B) from ACC/AHA 1
  • The 12-month duration is based on the CURE trial demonstrating mortality benefit 1

• Low bleeding risk with high thrombotic risk features: 1

  • Complex left main stenting
  • Two-stent bifurcation technique
  • Suboptimal stenting result
  • Prior stent thrombosis
  • Known CYP2C19 *2/*3 polymorphisms (clopidogrel poor metabolizers)
  • Multiple stents or long stent length
  • Diabetes mellitus with multivessel disease

• Event-free patients who tolerated initial DAPT course without bleeding complications 1

Consider Extended DAPT Beyond 12 Months (Up to 30 Months) If:

• Patient has tolerated DAPT without bleeding AND has high thrombotic risk but low bleeding risk 1
  • Class IIb recommendation (Level A) from both ACC/AHA and ESC 1
  • Extended DAPT (18-48 months vs 6-12 months) decreases MI (OR 0.67) and stent thrombosis (OR 0.45) but increases major hemorrhage (OR 1.58) 1
  • No mortality benefit with extended DAPT 1

Critical Pitfalls to Avoid

Do not discontinue DAPT at 3 months in ACS patients - this population requires minimum 12 months regardless of bleeding risk unless life-threatening bleeding occurs 1

Premature discontinuation increases risk - stopping DAPT early after stent placement significantly increases risk of stent thrombosis, MI, and death 2

If P2Y12 inhibitor must be stopped, continue aspirin - never discontinue both agents simultaneously if avoidable 1

Restart DAPT as soon as possible after any necessary interruption (e.g., surgery), given the substantial thrombotic hazard with lack of platelet inhibition 1

For patients requiring anticoagulation - after uncomplicated PCI in stable CAD, discontinue aspirin at 1 week and continue OAC plus clopidogrel for 6 months (or 12 months if high ischemic risk), then OAC alone 1

Specific Bleeding Risk Assessment

The 2024 ESC guidelines emphasize formal bleeding risk stratification at 3 months 1:

• High bleeding risk criteria should be systematically evaluated using validated definitions
• Ischemic risk assessment should consider anatomical complexity, clinical presentation, and procedural factors
• The balance between these risks determines continuation versus cessation