DAPT for NSTEMI Without Stent Placement
For NSTEMI patients managed without stent placement (medical management only), dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor should be continued for at least 12 months. 1
Recommended DAPT Regimen
Initial Antiplatelet Therapy
- Aspirin: 162-325 mg loading dose, then 75-100 mg daily indefinitely 2, 3
- P2Y12 Inhibitor Selection (in order of preference):
Duration of DAPT
The evidence strongly supports 12 months of DAPT for NSTEMI patients without stenting. 1 This recommendation is based on extrapolation from the CURE trial, which demonstrated a 21% absolute reduction in ischemic events with clopidogrel plus aspirin for up to 1 year in NSTE-ACS patients, the majority of whom were treated without revascularization 1.
Critical Evidence Base
The 2016 ACC/AHA guidelines explicitly state that available evidence from CURE, PLATO, and TRITON-TIMI 38 trials supports DAPT duration of at least 12 months for patients with NSTE-ACS, with benefit observed both in those treated with revascularization and in those treated with medical therapy alone 1.
Important caveat: The 2013 ACC/AHA STEMI guidelines note that among individuals who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients treated with medical therapy alone 1. However, the threshold for initiation of oral anticoagulation for secondary prevention may be lower in this population, especially if a shorter duration (14 days) of DAPT is planned 1.
P2Y12 Inhibitor Selection Algorithm
First-Line: Ticagrelor
- Ticagrelor is recommended over clopidogrel for medically managed ACS patients unless bleeding risk outweighs potential ischemic benefit 1
- Dose: 180 mg loading, then 90 mg twice daily 1
- Ticagrelor is considered a treatment option based on extrapolation of results from "medically managed" patients with ACS in the PLATO trial 1
Second-Line: Clopidogrel
- Use when ticagrelor cannot be administered due to contraindications, adverse effects, or patient intolerance 1
- Dose: 300-600 mg loading (600 mg preferred in younger patients <75 years), then 75 mg daily 1
- Clopidogrel is recommended in ACS patients who cannot receive ticagrelor or prasugrel, including those with prior intracranial bleeding 1
Avoid: Prasugrel
- Prasugrel is NOT recommended in medically managed ACS patients 1
- The FDA label and ESC guidelines explicitly state prasugrel should not be used in NSTEMI patients managed without PCI 1, 4
Special Considerations for Bleeding Risk
High Bleeding Risk Patients
If the patient has excessive bleeding risk (e.g., PRECISE-DAPT score ≥25), consider:
- Shorter DAPT duration may be reasonable, though the optimal duration is not well-established 1
- Continue aspirin indefinitely and reassess P2Y12 inhibitor continuation at regular intervals 1
Anticoagulation Considerations
For patients requiring oral anticoagulation (e.g., atrial fibrillation with CHADS2 ≥2, mechanical valves):
- The threshold for initiating anticoagulation may be lower in non-stented patients 1
- If triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) is needed, minimize duration to reduce bleeding risk 1
- Consider transitioning to anticoagulant plus single antiplatelet agent after initial period 1
Common Pitfalls to Avoid
Do not use prasugrel in medically managed NSTEMI patients—it is only indicated for patients undergoing PCI 1, 4
Do not discontinue DAPT prematurely in the first 12 months unless life-threatening bleeding occurs, as this increases risk of subsequent cardiovascular events 1
Do not assume shorter DAPT is adequate—while the evidence for duration beyond 14 days in non-stented patients is limited, the 12-month recommendation is based on strong evidence from the CURE trial 1
Monitor patients who stop DAPT early—those discontinuing DAPT before 12 months tend to have higher baseline risk and worse outcomes 5