How long should Dual Antiplatelet Therapy (DAPT) be continued after coronary stenting?

Duration of DAPT After Coronary Stenting

For acute coronary syndrome (ACS) patients, continue DAPT for at least 12 months; for stable coronary artery disease patients with newer-generation drug-eluting stents, 6 months is the minimum recommended duration, with 3 months acceptable in high bleeding risk patients. 1

Standard Duration by Clinical Presentation

Acute Coronary Syndrome (ACS)

• P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) combined with aspirin must be continued for at least 12 months after stent implantation, regardless of stent type (bare metal or drug-eluting). 1, 2
• This recommendation applies equally to STEMI and NSTE-ACS patients, as both represent the spectrum of acute coronary syndromes caused by plaque rupture. 1
• Ticagrelor should be used preferentially over clopidogrel for maintenance therapy. 1, 2
• Prasugrel is reasonable over clopidogrel in patients without high bleeding risk and no history of stroke or TIA. 1, 2

Stable Ischemic Heart Disease (SIHD)

• The minimum recommended duration has been reduced from 12 to 6 months for patients receiving newer-generation drug-eluting stents. 1
• This reduction is based on five randomized trials showing no increased risk of stent thrombosis with shorter duration (3-6 months) compared to 12 months in low-risk patients. 1
• High bleeding risk patients can discontinue DAPT at 3 months if they remain event-free. 3

Aspirin Dosing Throughout DAPT

• Daily aspirin dose should be 81 mg (range 75-100 mg) when used as part of DAPT. 1, 2
• This lower dose is recommended to minimize bleeding risk while maintaining antiplatelet efficacy. 1

Extended DAPT Beyond 12 Months

When to Consider Extension

• Patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk may continue beyond 12 months. 1, 3
• Extension is particularly reasonable in patients with high thrombotic risk features including: 3
  • Prior myocardial infarction or ACS presentation
  • Complex left main stenting
  • Two-stent bifurcation technique
  • Suboptimal stenting result
  • Prior stent thrombosis
  • Multiple stents implanted

Risk-Benefit Tradeoff

• Extended DAPT (18-48 months) reduces myocardial infarction (OR 0.67) and stent thrombosis (OR 0.45) but increases major hemorrhage (OR 1.58). 1, 3
• The absolute benefit translates to 3 fewer stent thromboses and 6 fewer MIs per 1000 patients treated, but 5 more major bleeds per 1000 patients per year. 1
• Post hoc analyses provide weak evidence of increased mortality with prolonged DAPT, though this remains controversial. 1

Early Discontinuation Considerations

High Bleeding Risk Patients

• Discontinuation at 6 months may be reasonable in ACS patients who develop high bleeding risk, are at high risk of severe bleeding complications (e.g., major intracranial surgery), or develop significant overt bleeding. 1, 2
• For stable CAD patients with high bleeding risk, discontinuation at 3 months is acceptable. 1, 3

Formal Assessment at 3 Months

• Evaluate bleeding risk using validated criteria at the 3-month mark. 3
• Assess thrombotic risk features including stent complexity, clinical presentation, and comorbidities. 3
• Patients with stable CAD, newer-generation DES, no high thrombotic risk features, and who have tolerated DAPT can discontinue at 3 months. 3

Special Populations

CABG Patients

• In ACS patients undergoing CABG, P2Y12 inhibitor therapy should be resumed after surgery to complete 12 months of DAPT. 1, 2
• Before CABG, discontinue P2Y12 inhibitors: at least 3 days for ticagrelor, 5 days for clopidogrel, and 7 days for prasugrel. 1, 2
• Aspirin should be continued throughout the perioperative period. 1

Fibrinolytic Therapy (STEMI)

• P2Y12 inhibitor (clopidogrel) should be continued for minimum 14 days and ideally at least 12 months. 1
• Extension beyond 12 months may be reasonable in patients tolerating therapy without bleeding. 1

Critical Pitfalls to Avoid

• Never use prasugrel in patients with prior stroke or TIA due to increased bleeding risk. 1, 2
• Do not prematurely discontinue DAPT within the first 12 months after ACS without compelling bleeding-related reasons. 2
• Avoid failing to reassess both bleeding and ischemic risks at regular intervals, particularly at 3 and 12 months. 3, 2
• Do not continue aspirin at doses higher than 100 mg daily when used as part of DAPT, as this increases bleeding without additional benefit. 1

Recent Evidence on Shorter Duration

• Emerging data from 2025 meta-analyses suggest that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and major bleeding without increasing ischemic complications, even in ACS patients. 4
• However, current ACC/AHA guidelines have not yet incorporated these findings, and the 12-month standard for ACS remains the official recommendation. 1, 2

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