As a cardiovascular pharmacist, you will hear debate about shorter dual antiplatelet therapy (DAPT) durations after a stent in acute coronary syndrome (ACS). The standard has been DAPT with aspirin AND a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) for 12 months, with the option to extend for those at 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 or 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 if shorter courses are better for patients with BOTH high bleeding and thrombotic risk.
Work with cardiology colleagues to tailor DAPT duration for ACS patients with a stent. 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, give 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. Provide early follow-up postdischarge. Document planned antithrombotic duration, verify patients have access to medications and educate about the DAPT regimen, emphasizing adherence.
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