What are the latest guideline recommendations for the duration of dual antiplatelet therapy after drug‑eluting stent implantation in stable coronary disease versus acute coronary syndrome, and how should bleeding risk or concomitant oral anticoagulation modify the regimen?

Latest Guideline on Antiplatelet Therapy Duration Post Coronary Stenting

For acute coronary syndrome (ACS), administer dual antiplatelet therapy (DAPT) for at least 12 months regardless of stent type; for stable coronary disease, administer DAPT for 6 months as the default duration. 1, 2

Standard DAPT Duration by Clinical Presentation

Acute Coronary Syndrome (NSTEMI/STEMI)

• Prescribe aspirin 75-100 mg daily plus a P2Y12 inhibitor for a minimum of 12 months after drug-eluting stent (DES) or bare-metal stent (BMS) implantation 1, 2
• This 12-month recommendation applies whether the patient receives PCI, CABG, or medical therapy alone 1, 2
• After completing 12 months, discontinue the P2Y12 inhibitor and continue aspirin 75-100 mg daily indefinitely 1, 3

Stable Ischemic Heart Disease (SIHD)

• Prescribe DAPT for 6 months as the default duration after DES implantation 1, 4
• For BMS, a minimum of 1 month DAPT is required 1
• Stent type (BMS vs DES) no longer dictates DAPT duration—clinical presentation and bleeding risk are the primary determinants 1, 3

P2Y12 Inhibitor Selection

For ACS Patients

• Ticagrelor (180 mg loading, 90 mg twice daily) is preferred over clopidogrel for maintenance therapy 1, 2, 3
• Prasugrel (60 mg loading, 10 mg daily) is reasonable over clopidogrel in patients without prior stroke/TIA and not at high bleeding risk 1, 2, 3
• Never prescribe prasugrel to patients with prior stroke or TIA due to increased cerebrovascular event risk 1, 5

For Stable CAD Patients

• Clopidogrel 75 mg daily is the default P2Y12 inhibitor 1, 3

Modified Duration Based on Bleeding Risk

High Bleeding Risk Patients

• For ACS with high bleeding risk, shorten DAPT to 6 months (may discontinue P2Y12 inhibitor after 6 months while continuing aspirin) 1, 2, 3
• For stable CAD with high bleeding risk, shorten DAPT to 3 months 1, 4, 3
• High bleeding risk is defined as a 1-year risk of serious bleeding ≥4% or intracranial hemorrhage risk ≥1%, including patients ≥65 years, low BMI, diabetes, prior bleeding, or on oral anticoagulation 5

Very High Bleeding Risk

• The absolute minimum DAPT duration is 1 month for all patients, even those at very high bleeding risk 4, 3
• If life-threatening bleeding occurs after 1 month, stop the P2Y12 inhibitor immediately but maintain aspirin to prevent catastrophic stent thrombosis 4, 3

Extended DAPT Beyond 12 Months

• For ACS patients who tolerate 12 months of DAPT without bleeding complications and remain at low bleeding risk, consider extending therapy beyond 12 months 1, 2
• Extension is particularly reasonable for patients with prior stent thrombosis, complex PCI (bifurcation requiring two stents, total stent length >60 mm, multiple lesions), or left main disease 3
• Recent meta-analysis data suggest that 3-month DAPT with high-potency P2Y12 inhibitor monotherapy may be acceptable for selected patients, though this represents emerging evidence 6

Patients Requiring Oral Anticoagulation

Triple Therapy Management

• Limit triple therapy (aspirin + P2Y12 inhibitor + oral anticoagulant) to a maximum of 1 month for most patients 1, 3
• For high ischemic risk ACS patients, triple therapy may extend up to 6 months 1
• Triple therapy increases bleeding risk 2-3 fold compared to oral anticoagulation alone 1, 3

Transition Strategy

• After 1 month, discontinue aspirin and continue dual therapy with oral anticoagulant plus clopidogrel (not ticagrelor or prasugrel) for up to 12 months 1, 3
• At 12 months, discontinue clopidogrel and continue oral anticoagulation alone 1, 3
• Use non-vitamin K antagonist oral anticoagulants (NOACs) at the lowest approved dose for stroke prevention when possible 1
• If using warfarin, target INR 2.0-2.5 (lower end of therapeutic range) 1

Mandatory Reassessment Timepoints

• At 6 months: reassess all patients—high bleeding risk individuals may discontinue the P2Y12 inhibitor 2, 3
• At 12 months: mandatory reassessment for every patient—a deliberate decision to continue or stop DAPT must be made 2, 3
• Failure to reassess at 12 months is considered a critical error 3

Bleeding Mitigation Strategies

• Prescribe low-dose aspirin 75-100 mg daily (higher doses provide no additional benefit and increase bleeding) 1, 4, 3
• Prescribe a proton pump inhibitor (PPI) to all patients on DAPT to reduce gastrointestinal bleeding risk 1, 4, 3
• PPIs are mandatory for patients with prior GI bleeding, advanced age, concomitant warfarin/NSAID use, or H. pylori infection 4
• Use radial artery access for PCI whenever feasible to reduce access-site bleeding 3

Critical Pitfalls to Avoid

• Never discontinue both aspirin and P2Y12 inhibitor simultaneously except in uncontrolled life-threatening bleeding where the source cannot be managed—this dramatically increases stent thrombosis mortality (20-45%) 4, 3
• Do not base DAPT duration on stent type alone—decisions must rely on clinical presentation (ACS vs stable CAD) and bleeding risk 1, 3
• Do not extend DAPT beyond 12 months without active reassessment balancing ongoing ischemic benefit against bleeding risk 3
• Avoid combining ticagrelor or prasugrel with oral anticoagulation—use clopidogrel only in triple therapy regimens 1, 3
• Do not perform elective noncardiac surgery within 30 days of BMS or 3 months of DES if DAPT must be discontinued perioperatively 1

Special Surgical Considerations

• For elective noncardiac surgery requiring P2Y12 inhibitor discontinuation, wait at least 3 months after DES implantation if the risk of delaying surgery is acceptable 1, 3
• For ACS patients undergoing CABG, resume P2Y12 inhibitor postoperatively to complete 12 months total DAPT duration from the ACS event 1, 2, 3