Tailor DAPT Duration for Patients at High Bleeding Risk

You’ll hear debate about shorter dual antiplatelet therapy (DAPT) durations after a stent in acute coronary syndrome (ACS).

The standard has been aspirin PLUS a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) for 12 months...with the option to extend for those with high thrombotic and low bleeding risk.

But mounting evidence suggests that 1 to 3 months of DAPT may be enough for select patients with ACS...such as those with high bleeding risk due to advanced age, prior GI bleeding, or prior intracranial bleeding.

In these cases, shorter DAPT courses seem to reduce bleeding without increasing CV risk...partly due to newer stent technology.

But it’s controversial. Limited data leave concerns that shorter courses may increase ischemic risk in patients with ACS and very high thrombotic risk...due to multiple stents, STEMI, etc.

There aren’t enough data to clarify whether shorter courses are better for patients with BOTH high bleeding and thrombotic risk.

Work with cardiology to tailor DAPT duration.

For example, consider using a scoring tool, such as PRECISE-DAPT, to help identify patients at high bleeding risk.

Generally stick with 12 months of DAPT for most ACS patients with a stent, especially if bleeding risk is lower...then reassess.

But consider just 1 to 3 months of DAPT for ACS patients with a stent if bleeding risk seems to outweigh thrombotic risk.

In these cases, consider DAPT for 1 to 3 months...followed by the P2Y12 inhibitor alone for up to 12 months...then a single antiplatelet indefinitely, usually aspirin or clopidogrel.

So far, most data with shorter durations are with clopidogrel or ticagrelor...there are fewer studies with prasugrel.

Ensure planned antithrombotic duration is documented in the discharge summary...verify that patients have access to meds...and educate about the DAPT regimen, emphasizing adherence.

For stent patients who also have atrial fib, review our article to help manage anticoagulant and antiplatelet combos.

Use our resource, Dual Antiplatelet Therapy, to find recommendations for patients with stable ischemic heart disease.

Key References

  • Circulation. 2022 Jan 18;145(3):e18-e114
  • Eur Heart J. 2023 Mar 14;44(11):954-968
  • Am Heart J. 2022 Sep;251:101-114
  • JAMA Cardiol. 2022 Apr 1;7(4):407-417
Hospital Pharmacist’s Letter. June 2023, No. 390615



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