When should Dual Antiplatelet Therapy (DAPT) be reassessed?

When to Reassess DAPT Therapy

DAPT should be systematically reassessed at specific time intervals: at 6 months for high bleeding risk patients, at 12 months for all patients to determine continuation beyond the standard duration, and whenever clinical circumstances change (new bleeding events, need for anticoagulation, or planned surgery).

Critical Reassessment Timepoints

At 6 Months Post-PCI or ACS

• For high bleeding risk patients (those on oral anticoagulation, with coagulopathy, prior bleeding on DAPT, or requiring major intracranial surgery), discontinuation of the P2Y12 inhibitor after 6 months may be reasonable while continuing aspirin 1
• The European Society of Cardiology recommends shortened 6-month therapy for high bleeding risk patients 2
• High bleeding risk is traditionally defined as ≥4% annual risk of serious bleeding or ≥1% risk of intracranial hemorrhage, including patients ≥65 years old, low BMI (<18.5), diabetes, or prior bleeding 3

At 12 Months Post-ACS or PCI

• This is the mandatory reassessment point for all patients completing the standard DAPT duration 1
• For ACS patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation beyond 12 months may be reasonable 1
• The European Society of Cardiology suggests therapy >12 months may be considered for patients tolerating DAPT without bleeding complications 2
• Recent meta-analysis shows short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and bleeding without differences in thrombotic outcomes 4

For Stable Ischemic Heart Disease (SIHD) Patients

• Reassess at 1 month, 3 months, 6 months, and 12 months following the treatment algorithm 1
• At 1 month: minimum duration for clopidogrel in SIHD patients 1
• At 3-6 months: if no high bleeding risk and no significant overt bleeding, continuation to 12 months may be reasonable 1
• At 12 months: further continuation may be reasonable if bleeding risk remains low 1

Immediate Reassessment Triggers

Development of High Bleeding Risk

• Initiation of oral anticoagulation (increases bleeding risk 2-3 fold) - triple therapy should be limited to maximum 6 months or omitted after hospital discharge 2
• Significant overt bleeding on DAPT requires immediate reassessment for early P2Y12 inhibitor discontinuation 1
• Planned major surgery, especially intracranial procedures 1

Scheduled Surgery Considerations

• Wait at least 1 month after stent implantation before elective surgery requiring P2Y12 inhibitor discontinuation 2
• For elective procedures, consider withholding P2Y12 inhibitor 5 days before while continuing aspirin 5
• Never discontinue both antiplatelet agents simultaneously due to high stent thrombosis risk 5

Special Clinical Scenarios Requiring Reassessment

• Prior stent thrombosis without correctable causes warrants prolonged DAPT 2
• Post-CABG patients with ACS should have P2Y12 inhibitor resumed after surgery to complete 12 months of DAPT 1
• Patients with diabetes or prior MI on ticagrelor may benefit from reduced-dose ticagrelor 60 mg BID after the first year 6

Key Reassessment Considerations

Bleeding vs. Ischemic Risk Balance

• Prolonged DAPT beyond 12 months reduces stent thrombosis and major adverse cardiovascular events but increases bleeding risk 7
• The DAPT score can help guide decisions, though it has limitations 6
• Recent evidence suggests P2Y12 inhibitor monotherapy (especially ticagrelor) after short DAPT reduces net adverse clinical events in both ACS and chronic coronary syndrome 4

Agent-Specific Contraindications

• Prasugrel must be discontinued if patient develops stroke or TIA (contraindicated in patients with prior cerebrovascular events) 1
• Avoid prasugrel in patients >75 years or <60 kg 3

Common Pitfall

The most critical error is failing to reassess at 12 months - this is when the decision to continue or discontinue must be actively made rather than allowing patients to continue indefinitely by default 1.

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