DAPT duration for patients at HIGH bleeding risk

Tailor dual antiplatelet therapy (DAPT) duration for patients at high bleeding risk....

Overview

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.

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Optimizing dual antiplatelet therapy (DAPT) duration

Considerations for shortening DAPT in high-bleeding-risk patients

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.

Guidance for tailoring DAPT Duration

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 post-discharge. Document planned antithrombotic duration, verify patients have access to medications and educate about the DAPT regimen, emphasizing adherence.

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References

Lawton JS, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e18-e114.
Costa F, Montalto C, Branca M, et al. Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials. Eur Heart J. 2023 Mar 14;44(11):954-968.
Park DY, Wang P, et al. Shortening the duration of dual antiplatelet therapy after percutaneous coronary intervention for acute coronary syndrome: A systematic review and meta-analysis. Am Heart J. 2022 Sep;251:101-114.
Watanabe H, Morimoto T, ey al. Comparison of Clopidogrel Monotherapy After 1 to 2 Months of Dual Antiplatelet Therapy With 12 Months of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndrome: The STOPDAPT-2 ACS Randomized Clinical Trial. JAMA Cardiol. 2022 Apr 1;7(4):407-417.