ACS indicates acute coronary syndrome; ASA, aspirin; CCD, chronic coronary disease; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; DOAC, direct oral anticoagulant; MI, myocardial infarction; OAC, oral anticoagulants; PCI, percutaneous coronary intervention; SAPT, single antiplatelet therapy. *Colors correspond to Class of Recommendation in 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines | Circulation
Lectures
Podcasts
#400 Antiplatelets, Anticoagulation for Coronary Artery Disease and Afib - The Curbsiders
Short-Term Dual Antiplatelet T… - Star Update Podcast - Cardiology News Summaries - Apple Podcasts
Video
Dual Antiplatelet Therapy: Whiteboard Animation | Core IM Podcast
Calculators
DAPT Risk Calculator : compares bleeding to ischemic risk to aid in shared decision making of extending DAPT therapy
PRECISE DAPT: Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy
PARIS Bleeding Risk Score Calculator - Appcardio : Assesses the risk of bleeding and adverse events in patients with coronary stents who are receiving DAPT
Resources
Guidelines
Articles
PEGASUS-TIMI Long-Term Use of Ticagrelor in Patients with Prior Myocardial Infarction | New England Journal of Medicine
21,162 patients w/ MI 1-3 years earlier on low-dose aspirin
Ticagrelor 90 mg BID or 60 mg BID compared w/ placebo
Treatment w/ ticagrelor 60 mg BID reduced risk of CV death, MI, or stroke (HR 0.84; 95%CI 0.74-0.95) but increased risk of major bleeding (HR 2.32; 95%CI 1.68-3.21)
Bottom line: CCD w/ previous MI and low bleed risk: may extend DAPT beyond 12 months for a period of up to 3 years to reduce major adverse cardiovascular events (MACE)
563 patients with nonvalvular afib indicated for anticoagulation and underwent PCI
Bottom Line: Double Therapy (P2Y12 + Clopidogrel) vs. Triple Therapy (P2Y12 + Clopidogrel + ASA) was associated with a significant reduction in bleeding complication 19.4% vs. 44.4% (HR 0.36; 95% CI 0.26-0.50; P<0.0001; NNT 4)
PLATO Trial Ticagrelor versus clopidogrel in patients with acute coronary syndromes - PubMed
18, 624 patients admitted to the hospital with ACS
Ticagrelor vs Clopidogrel
Death from vascular cause, MI, and stroke at 12 months 9.8% vs. 11.7% HR 0.84 (95%CI 0.77-0.92)
No significant differences in major bleeding 11.6% vs. 11.2% HR 1.04 (95% CI 0.95-1.13)
Patients aged 18 years or older with acute coronary syndrome (ACS) who completed the IVUS-ACS study and had no major ischemic or bleeding events after 1 month of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) with contemporary drug-eluting stents.
Ticagrelor monotherapy (90 mg twice daily) from month 1 to month 12 after PCI compared to Ticagrelor (90 mg twice daily) plus aspirin (100 mg once daily) from month 1 to month 12 after PCI.
Ticagrelor monotherapy after 1 month less clinically relevant bleeding (HR 0.45; 95% CI 0.30-0.66) without increased thrombotic risk of composite of cardiac death, myocardial infarction, ischemic stroke, definite stent thrombosis, or clinically driven target vessel revascularization (HR 0.98; 95% CI 0.69-1.39)
References
•Virani S. S., Newby, L. K., Arnold, S. V., et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease: a report of the American heart association/american college of cardiology joint committee on clinical practice guidelines. Circulation. 2023;148(9):9-119.
•Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015;372(19):1791-1800.
•Choi KH, Park YH, Song YB, et al. Long-term Effects of P2Y12 Inhibitor Monotherapy After Percutaneous Coronary Intervention: 3-Year Follow-up of the SMART-CHOICE Randomized Clinical Trial. JAMA Cardiol. 2022;7(11):1100-1108.
•Watanabe H, Morimoto T, Natsuaki M, et 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;7(4):407-417.
•Mehran R, Baber U, Sharma SK, et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N Engl J Med. 2019;381(21):2032-2042.
•Gragnano F, Zwahlen M, Vranckx P, et al. Ticagrelor Monotherapy or Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation: Per-Protocol Analysis of the GLOBAL LEADERS Trial. J Am Heart Assoc. 2022;11(10):e024291.
•Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107-1115.
•Gibson CM, Mehran R, Bode C, et al. Prevention of Bleeding in Patients with Atrial Fibrillation Undergoing PCI. N Engl J Med. 2016;375(25):2423-2434.
•Lopes RD, Heizer G, Aronson R, et al. Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. N Engl J Med. 2019;380(16):1509-1524.
•Ge Z, Kan J, Gao X, et al. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial [published correction appears in Lancet. 2024 May 11;403(10439):1854. doi: 10.1016/S0140-6736(24)00929-2.]. Lancet. 2024;403(10439):1866-1878.
•Wallentin L, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045-1057.
•Presented by Dr. Hyo-Soo Kim at the American College of Cardiology Annual Scientific Session (ACC.25), Chicago, IL, March 29, 2025.
•Carvalho PEP, Gewehr DM, Nascimento BR, et al. Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. JAMA Cardiol. 2024;9(12):1094-1105.
•Joseph M, Krishna MM, Ezenna C, et al. Short Versus One-Year Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: an Updated Meta-Analysis. Am J Cardiol. 2025;237:17-28.
•Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without Aspirin in Stable Cardiovascular Disease. N Engl J Med. 2017;377(14):1319-1330.