Can DAPT (Dual Antiplatelet Therapy) be stopped 6 months post PCI (Percutaneous Coronary Intervention) in a patient with UGIB (Upper Gastrointestinal Bleeding)?

From the Guidelines

DAPT can be stopped 6 months post PCI in a patient with UGIB, but this decision should be made on a case-by-case basis, considering the patient's individual risk of bleeding and ischemic events.

Key Considerations

• The 2024 ESC guidelines recommend DAPT for up to 6 months after PCI-stenting, but also suggest that stopping DAPT after 1-3 months may be considered in patients who are not at high bleeding risk nor at high risk of ischemic events 1.
• In patients at high bleeding risk, discontinuation of DAPT after 1-3 months should be considered, and in those with a very high risk of life-threatening bleeding, DAPT may be considered for only 1 month 1.
• The decision to stop DAPT should be individualized, taking into account the patient's risk factors, such as age, comorbidities, and history of bleeding or ischemic events.

DAPT Duration

• The default duration of DAPT is 6 months, but this can be adjusted based on the patient's risk profile 1.
• In patients with ACS, DAPT is recommended for at least 12 months, unless there are contraindications such as an excessive risk of bleeding 1.
• De-escalation of P2Y12 inhibitor treatment may be considered as an alternative DAPT strategy, especially for ACS patients deemed unsuitable for 12-month potent platelet inhibition 1.

Bleeding Risk Assessment

• The PRECISE-DAPT score can be used to assess the risk of bleeding in patients undergoing DAPT 1.
• Patients with a high bleeding risk, such as those with a history of gastrointestinal bleeding, should be closely monitored and considered for a shorter duration of DAPT 1.

Clinical Judgment

• The decision to stop DAPT should be made on a case-by-case basis, taking into account the patient's individual risk factors and clinical presentation 1.
• Clinicians should carefully weigh the benefits and risks of continuing or stopping DAPT, considering the patient's overall health status and medical history.

From the Research

Stopping DAPT 6 Months Post PCI in Patients with UGIB

• The decision to stop DAPT 6 months post PCI in patients with UGIB should be based on individual patient risk factors and clinical judgment 2, 3, 4, 5, 6.
• Studies have shown that short-term DAPT (≤3 months) may be a valid option for patients undergoing PCI, with reduced risk of major bleeding and net adverse clinical events compared to standard DAPT (6-12 months) 5, 6.
• However, patients with high bleeding risk, such as those with UGIB, may require careful consideration of the optimal DAPT duration, as they may be at increased risk of ischemic events if DAPT is discontinued too early 2, 6.
• A meta-analysis of randomized controlled trials found that short-term DAPT significantly reduced major bleeding and any bleeding in patients with high bleeding risk, while the risk of other outcomes was not statistically different 6.
• Another study found that 6-month DAPT duration was not inferior to 12-month DAPT duration in patients with PCI of an unprotected left main coronary artery stenosis and stable angina, with comparable rates of stent thrombosis and bleeding 4.

Key Considerations

• Patient-specific factors, such as age, comorbidities, and history of bleeding or ischemic events, should be taken into account when determining the optimal DAPT duration 2, 3.
• The type of stent used (e.g., drug-eluting vs. bare metal) and the presence of other cardiovascular risk factors may also influence the decision to stop DAPT 6 months post PCI 3, 5.
• Close monitoring of patients after DAPT discontinuation is essential to promptly identify and manage any potential ischemic or bleeding complications 2, 6.