2026 ACC Scientific Statement: Antiplatelet therapy enters the era of personalized, risk-guided care.
2026 ACC Scientific Statement: Antiplatelet therapy enters the era of personalized, risk-guided care.
Source: JACC, 2026 ACC Scientific Statement (June 30, 2026).
Treatment should balance ischemic and bleeding risks using clinical assessment and validated tools (DAPT score for ischemic benefit vs bleeding, PRECISE-DAPT and ARC-HBR for bleeding risk).
• Routine aspirin for primary prevention is no longer recommended in unselected adults; it should be considered only in adults 40–70 years at high ASCVD risk and low bleeding risk, and generally avoided after age 70.
Antiplatelet Therapy After ACS-PCI:
• Default strategy: 12 months of DAPT remains the standard after ACS-PCI.
• P2Y12 inhibitor: Ticagrelor or prasugrel are preferred over clopidogrel, while clopidogrel remains appropriate in many older patients or those at higher bleeding risk.
• If bleeding risk is high and ischemic risk is low (e.g., ARC-HBR, elderly/frail patients, prior bleeding, oral anticoagulation, CKD, or anemia), DAPT may be shortened to 1–3 months, followed by ticagrelor or prasugrel monotherapy to reduce bleeding.
• If ischemic risk is high (e.g., STEMI with large thrombus burden, LM/complex PCI , CKD, or prior MI ), the standard 12-month DAPT strategy should generally be maintained.
• Patients with both high bleeding and high ischemic risk require individualized treatment, balancing both risks.
In summary:
Default → 12-month DAPT
High bleeding + no high ischemic risk → Short DAPT (1–3 months) → P2Y12 monotherapy
High ischemic risk → Continue 12-month DAPT
Both high → Individualized decision
• Beyond 1 year after MI/ACS, antiplatelet therapy should be individualized; emerging evidence suggests clopidogrel monotherapy may outperform aspirin for long-term secondary prevention in selected patients.
• In patients requiring oral anticoagulation (e.g., AF), prolonged triple therapy should be avoided, favoring early aspirin discontinuation and simplified regimens to reduce bleeding.
https://www.jacc.org/doi/10.1016/j.jacc.2026.05.037
