What are the indications for Dual Antiplatelet Therapy (DAPT) and Direct Oral Anticoagulants (DOAC)?

From the Guidelines

Dual Antiplatelet Therapy (DAPT) and Direct Oral Anticoagulants (DOAC) are indicated in specific clinical scenarios to balance the risk of thrombosis and bleeding.

Indications for DAPT and DOAC

• Atrial Fibrillation (AF) with Acute Coronary Syndromes (ACS) or undergoing Percutaneous Intervention (PCI): DAPT is recommended for up to 12 months, with a preference for a DOAC over a Vitamin K Antagonist (VKA) to mitigate bleeding risk and prevent thromboembolism 1.
• AF patients with chronic coronary or vascular disease: Antiplatelet therapy beyond 12 months is not recommended in stable patients treated with oral anticoagulation, due to lack of efficacy and to avoid major bleeding 1.
• Patients with an indication for oral anticoagulation undergoing PCI: Early cessation of aspirin (≤1 week) and continuation of an oral anticoagulant and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months is recommended to avoid major bleeding, if ischaemic risk is low 1.
• ACS patients: The default DAPT duration is 12 months, with 6-month therapy duration considered in high bleeding risk patients, and >12-month therapy may be considered in ACS patients who have tolerated DAPT without a bleeding complication 1.

Specific Recommendations

• Rivaroxaban and Dabigatran dosing: When combined with antiplatelet therapy, rivaroxaban 15 mg once daily and dabigatran 110 mg twice daily should be considered in preference to higher doses, when concerns about bleeding risk prevail over concerns about stent thrombosis or ischaemic stroke 1.
• Triple therapy with aspirin, clopidogrel, and oral anticoagulation: Should be considered in patients with AF when ischaemic risk outweighs the bleeding risk, with the total duration (≤1 month) decided according to assessment of these risks and clear documentation of the discharge treatment plan 1.

Key Considerations

• Bleeding risk assessment: An individualized approach based on ischaemic vs. bleeding risk assessment is warranted to guide the duration of DAPT and the use of DOACs 1.
• P2Y12 inhibitor selection: Clopidogrel is considered the default P2Y12 inhibitor in patients with stable CAD treated with PCI, those with indication to concomitant oral anticoagulation, as well as in ACS patients in whom ticagrelor or prasugrel are contraindicated 1.

From the Research

Indications for Dual Antiplatelet Therapy (DAPT)

• DAPT is a cornerstone of antithrombotic treatment in patients undergoing percutaneous coronary intervention 2
• The optimal duration of DAPT depends on the risk of bleeding and thrombosis, with shorter durations recommended for patients at high bleeding risk 2, 3
• DAPT is indicated for patients with acute coronary syndrome, with the goal of preventing ischemic complications, including stent thrombosis 2, 4

Indications for Direct Oral Anticoagulants (DOACs)

• DOACs are preferred over vitamin K antagonists in patients with atrial fibrillation and coronary artery disease 2, 5
• DOACs are indicated for patients with acute coronary syndrome who are at high thromboembolic risk 4
• The addition of a DOAC to antiplatelet therapy can reduce the risk of major ischemic events in patients with acute coronary syndrome 4

Combination Therapy with DAPT and DOACs

• The combination of DAPT and DOACs can increase the risk of bleeding, and the benefits and risks of this approach should be carefully considered 6
• Dual therapy with a DOAC and single antiplatelet therapy can be as effective as triple therapy with a DOAC and DAPT, with a lower risk of bleeding 5
• The optimal duration of DAPT and DOAC therapy depends on individual patient characteristics and bleeding risk 3