What is the recommended duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) and non-ACS?

Duration of DAPT Post-DES in ACS and Non-ACS

For ACS patients post-DES implantation, maintain DAPT for at least 12 months regardless of stent type, using ticagrelor or prasugrel over clopidogrel when no contraindications exist. 1 For non-ACS (stable CAD) patients, 6 months of DAPT is the standard duration, with flexibility to shorten to 1-3 months in high bleeding risk patients or extend up to 30 months in low bleeding risk/high ischemic risk patients. 1

ACS Patients (STEMI and NSTE-ACS)

Standard Duration

• Minimum 12 months of DAPT is mandatory (Class I, Level B) for all ACS patients treated with DES, BMS, or medical therapy alone 1
• This recommendation stems from the CURE trial and has been extrapolated across the ACS spectrum (NSTE-ACS and STEMI) 1
• Use aspirin 75-100 mg daily combined with a P2Y12 inhibitor 1, 2

P2Y12 Inhibitor Selection

• Ticagrelor is preferred over clopidogrel for maintenance therapy (Class IIa, Level B) 1
• Prasugrel is reasonable over clopidogrel in patients without prior stroke/TIA and not at high bleeding risk (Class IIa, Level B) 1
• Prasugrel is contraindicated (Class III: Harm) in patients with prior stroke or TIA 1, 2

Duration Modification Based on Bleeding Risk

High Bleeding Risk Patients:

• May discontinue P2Y12 inhibitor at 6 months if high bleeding risk develops (e.g., need for oral anticoagulation, major surgery planned, significant overt bleeding) (Class IIb, Level C) 1
• This represents a pragmatic compromise between stent thrombosis protection and bleeding prevention 1

Low Bleeding Risk/High Ischemic Risk Patients:

• Extension beyond 12 months may be reasonable (Class IIb, Level A) in patients who tolerate DAPT without bleeding complications 1
• Consider continuation if no prior bleeding on DAPT, no coagulopathy, and no oral anticoagulant use 1

Emerging Evidence Challenging 12-Month Standard

• Recent data suggests the 12-month duration lacks prospective validation and was extrapolated from trials with median durations of 9 months (CURE) or 15 months (prasugrel studies) 3
• Multiple de-escalation strategies (switching to clopidogrel, dose reduction, or shortening DAPT with ticagrelor monotherapy) reduce bleeding without increasing ischemic events 3
• A 2025 meta-analysis showed short DAPT (≤3 months) followed by ticagrelor monotherapy reduced net adverse clinical events and major bleeding in ACS patients without increasing MACE 4

Clinical Caveat: Despite emerging evidence favoring shorter durations with P2Y12 monotherapy, current ACC/AHA guidelines maintain 12 months as the only Class I recommendation 1, 3

Non-ACS Patients (Stable CAD)

Standard Duration

• 6 months of DAPT is the default for DES implantation in stable CAD (Class I, Level B) 1
• This represents a shift toward shorter durations compared to historical 12-month recommendations 1

High Bleeding Risk Patients

• 3 months of DAPT is reasonable (Class IIa, Level B) 1
• 1 month of DAPT may be considered (Class IIb, Level C) in very high bleeding risk patients 1
• High bleeding risk includes: advanced age, oral anticoagulant use, thrombocytopenia, active cancer, prior bleeding 1

Low Bleeding Risk/High Ischemic Risk Patients

• Extension up to 30 months may be considered (Class IIb, Level A) in patients who tolerate DAPT without complications 1
• This applies to patients with high thrombotic risk who remain at low bleeding risk 1

BMS and Special Devices

• BMS: 1 month minimum DAPT (Class I, Level A) 1
• Drug-coated balloons: 6 months DAPT (Class IIa, Level B) 1
• Bioresorbable scaffolds: 12 months DAPT (Class IIa, Level C) 1

Algorithmic Approach to DAPT Duration

Step 1: Identify Clinical Presentation

• ACS (STEMI/NSTE-ACS) → Proceed to Step 2A
• Stable CAD → Proceed to Step 2B

Step 2A: ACS Pathway

• Default: 12 months DAPT 1
• Assess bleeding risk at baseline and throughout treatment
• High bleeding risk develops → Consider 6-month discontinuation 1
• Low bleeding risk + high ischemic risk + tolerates DAPT → Consider extension beyond 12 months 1

Step 2B: Stable CAD Pathway

• Default: 6 months DAPT 1
• High bleeding risk → Shorten to 3 months (or 1 month if very high risk) 1
• Low bleeding risk + high ischemic risk → Consider extension to 30 months 1

Step 3: P2Y12 Inhibitor Selection

• ACS: Ticagrelor or prasugrel preferred over clopidogrel 1
• Stable CAD: Clopidogrel is standard (Class I, Level A) 1
• Contraindication check: No prasugrel if prior stroke/TIA 1, 2

Step 4: Aspirin Dosing

• Use low-dose aspirin 75-100 mg daily throughout DAPT and indefinitely after P2Y12 inhibitor discontinuation 1, 2

Critical Pitfalls to Avoid

• Do not use prasugrel in patients with prior stroke/TIA – this is a Class III (Harm) recommendation with increased bleeding risk 1, 2
• Do not automatically continue 12-month DAPT in high bleeding risk patients – assess bleeding risk dynamically and consider early discontinuation at 6 months in ACS or 1-3 months in stable CAD 1
• Do not use high-dose aspirin (>100 mg) – no additional benefit and increased bleeding risk 1, 2
• Do not stop DAPT prematurely without assessing both bleeding and ischemic risk – balance is essential for net clinical benefit 1