What is the recommended duration for maintaining aspirin and clopidogrel (Dual Antiplatelet Therapy (DAPT)) in a patient with Acute Coronary Syndrome Non-ST-Elevation Myocardial Infarction (ACS NSTEMI)?

Duration of Dual Antiplatelet Therapy for ACS NSTEMI

For patients with ACS NSTEMI, aspirin and clopidogrel (or another P2Y12 inhibitor) should be continued for at least 12 months, regardless of whether they undergo PCI, receive medical therapy alone, or undergo CABG. 1

Standard DAPT Duration: 12 Months Minimum

The ACC/AHA guidelines provide a Class I recommendation (strongest level) that P2Y12 inhibitor therapy combined with aspirin should be continued for at least 12 months in all ACS patients, including those with NSTEMI. 1 This applies across all treatment strategies:

• Medical therapy alone (no revascularization): Continue DAPT for at least 12 months 1
• PCI with stent placement (BMS or DES): Continue DAPT for at least 12 months 1
• CABG: Resume P2Y12 inhibitor postoperatively to complete 12 months of DAPT therapy after the ACS event 1, 2

Aspirin Dosing

Maintain aspirin at 81 mg daily (acceptable range 75-100 mg) when used as part of DAPT. 1 This low-dose regimen provides equivalent antiplatelet efficacy while minimizing bleeding risk compared to higher doses (325 mg), which are no longer recommended for maintenance therapy. 3, 4

P2Y12 Inhibitor Selection

Ticagrelor or prasugrel are preferred over clopidogrel for NSTEMI patients. 1, 5, 6

• Ticagrelor: Class IIa recommendation as preferred agent over clopidogrel (180 mg loading dose, then 90 mg twice daily) 1, 5
• Prasugrel: Reasonable alternative for patients without history of stroke/TIA and not at high bleeding risk (60 mg loading dose, then 10 mg daily) 1, 6
• Clopidogrel: Reserve for patients with contraindications to more potent agents, prior stroke/TIA (prasugrel contraindicated), or high bleeding risk (600 mg loading dose, then 75 mg daily) 6, 3

Critical contraindication: Prasugrel should NOT be administered to patients with prior stroke or TIA (Class III: Harm recommendation). 1, 2

Extension Beyond 12 Months

In patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation beyond 12 months may be reasonable (Class IIb recommendation). 1

Consider extended DAPT if the patient has:

• No bleeding complications during initial 12 months 1, 2
• No high bleeding risk factors (prior bleeding on DAPT, coagulopathy, oral anticoagulant use) 1
• Complex coronary disease or high ischemic risk 2

For extended therapy beyond 12 months, ticagrelor 60 mg twice daily (not 90 mg) is the approved dose for long-term secondary prevention. 2

Early Discontinuation (Shortened Duration)

In patients who develop high bleeding risk or experience significant bleeding, discontinuation of P2Y12 therapy after 6 months may be reasonable (Class IIb recommendation). 1, 2 High bleeding risk includes:

• Treatment with oral anticoagulant therapy 1
• Major intracranial surgery planned 1
• Significant overt bleeding 1, 2
• PRECISE-DAPT score ≥25 6, 3

Perioperative Management for CABG

If CABG is required, discontinue P2Y12 inhibitors before surgery to reduce bleeding risk: 2

• Ticagrelor: Stop at least 3 days before surgery 2
• Clopidogrel: Stop at least 5 days before surgery 2
• Prasugrel: Stop at least 7 days before surgery 2

Resume P2Y12 inhibitor postoperatively to complete the full 12-month DAPT course after the ACS event. 1, 2

Bleeding Risk Mitigation

Prescribe a proton pump inhibitor (PPI) with DAPT to reduce gastrointestinal bleeding risk. 6, 3 This simple intervention significantly reduces bleeding complications without compromising antiplatelet efficacy. 6

Common Pitfalls to Avoid

• Do not discontinue DAPT prematurely (especially within first month after stent placement or first 12 months after ACS) without compelling bleeding or surgical reasons 2, 6
• Do not use aspirin doses >100 mg daily when combined with P2Y12 inhibitor—this increases bleeding without improving efficacy 5, 2, 3
• Do not use prasugrel in patients with prior stroke/TIA—this is a Class III (Harm) contraindication 1, 2, 6
• Do not continue ticagrelor 90 mg twice daily for prolonged therapy beyond 12 months—reduce to 60 mg twice daily for extended secondary prevention 2
• Do not omit PPI co-prescription—this significantly reduces GI bleeding risk 6, 3