How long should dual antiplatelet therapy be given after percutaneous coronary intervention?

Duration of Dual Antiplatelet Therapy After PCI

For acute coronary syndrome (ACS) patients undergoing PCI, dual antiplatelet therapy (DAPT) should be continued for at least 12 months regardless of stent type (bare-metal or drug-eluting), while for stable ischemic heart disease (SIHD) patients, DAPT should be given for a minimum of 6 months after drug-eluting stent implantation or 1 month after bare-metal stent placement. 1, 2

ACS Patients Post-PCI: 12-Month Standard

The cornerstone recommendation is 12 months of DAPT for all ACS presentations (STEMI and NSTE-ACS) treated with PCI, irrespective of whether a bare-metal stent or drug-eluting stent was implanted. 1, 2, 3 This Class I, Level B-R recommendation reflects robust randomized trial evidence demonstrating reduced ischemic events with this duration.

P2Y12 Inhibitor Selection for ACS:

• Ticagrelor 90 mg twice daily is the preferred P2Y12 inhibitor for most ACS patients after PCI (Class IIa recommendation). 1, 2, 3
• Prasugrel 10 mg daily is a reasonable alternative for patients without prior stroke/TIA, age <75 years, and weight ≥60 kg (Class IIa recommendation). 1, 2, 3
• Clopidogrel 75 mg daily should be reserved only when ticagrelor or prasugrel are unavailable or contraindicated. 2, 3
• Aspirin dose must be 75-100 mg daily throughout DAPT—higher doses increase bleeding without improving efficacy. 1, 2, 3

Modifying Duration in ACS Patients:

Shortening to 6 months may be reasonable (Class IIb, Level C-LD) if patients develop high bleeding risk during treatment, such as requiring oral anticoagulation, facing major intracranial surgery, or experiencing significant overt bleeding. 1, 2

Extending beyond 12 months may be reasonable (Class IIb, Level A-SR) for patients who have tolerated DAPT without bleeding complications and remain at low bleeding risk, particularly those with high ischemic/thrombotic risk features. 1, 2, 3

SIHD Patients Post-PCI: Shorter Duration

For stable ischemic heart disease patients undergoing elective PCI:

• Drug-eluting stents require 6 months of DAPT (Class I recommendation). 2, 4, 3
• Bare-metal stents require only 1 month of DAPT (Class I recommendation). 4, 3

After completing the minimum DAPT duration, transition to single antiplatelet therapy (aspirin 75-100 mg daily or clopidogrel 75 mg daily) should occur. 4, 3

Special Populations Requiring Oral Anticoagulation

For patients with atrial fibrillation or other indications for oral anticoagulation (OAC) undergoing PCI, the approach differs substantially:

Default Strategy (Most Patients):

• Peri-PCI hospitalization: Triple therapy (OAC + aspirin + clopidogrel). 1, 3
• Post-discharge: Aspirin should be stopped within 1 week; continue double therapy (OAC + clopidogrel) for 6-12 months based on ischemic risk. 1, 3
• After 6-12 months: Discontinue clopidogrel; continue OAC monotherapy at full stroke-prevention dose. 1, 3

High Ischemic/Low Bleeding Risk Patients:

• Triple therapy may be extended up to 1 month (rarely beyond) after PCI. 1
• Non-vitamin K antagonist oral anticoagulants (NOACs) are strongly preferred over warfarin unless contraindicated. 1, 3
• Clopidogrel is the P2Y12 inhibitor of choice when combined with OAC—prasugrel and ticagrelor carry higher bleeding risk in this context. 1

Critical Pitfalls to Avoid

Never administer prasugrel to patients with prior stroke or TIA—this is a Class III: Harm recommendation with documented increased cerebrovascular event risk. 1, 2, 3

Never discontinue both antiplatelet agents within the first month after stent placement, even for elective surgery, as this dramatically increases the risk of catastrophic stent thrombosis, myocardial infarction, and death. 1, 3

Never maintain long-term triple therapy (OAC + aspirin + P2Y12 inhibitor) beyond the recommended duration, as bleeding risk increases 2-3 fold without proportional ischemic benefit. 1, 3

Never omit proton pump inhibitor (PPI) prescription with DAPT—all patients should receive a PPI (Class I recommendation) to reduce gastrointestinal bleeding risk without affecting antiplatelet efficacy. 2, 3

Never use aspirin doses >100 mg daily when combined with a P2Y12 inhibitor, as this increases bleeding without improving outcomes. 2, 3

Post-CABG Management

For ACS patients who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed postoperatively to complete the full 12-month course of DAPT. 1, 2 This ensures adequate protection against recurrent ischemic events during the critical first year after ACS.

ACS Without Revascularization

For ACS patients managed medically without PCI or fibrinolytic therapy, DAPT should still be continued for at least 12 months using clopidogrel or ticagrelor (ticagrelor preferred for NSTE-ACS). 1, 2