Key Points Summary Title: Is a Year of Dual Antiplatelet Therapy Magical Thinking?
Key Points Summary
Title: Is a Year of Dual Antiplatelet Therapy Magical Thinking?
Author: Christopher Labos, MD, CM, MSc
Date: May 12, 2025
Source: Medscape Commentary
1. Historical Context:
• The CURE trial (2001) launched the era of DAPT (aspirin + clopidogrel).
• Later trials (TRITON-TIMI 38 and PLATO) reinforced DAPT use, though they didn’t specifically test 12-month duration.
2. Why 12 Months?
• Initially recommended due to high stent thrombosis rates with early-generation DES.
• Persisted over time despite improvements in stents and procedural techniques.
3. Evidence on Duration:
• DAPT trial: 30 months > 12 months in preventing events, but increased bleeding.
• Meta-analyses: Longer DAPT reduces CV events but raises bleeding risk.
• Shorter durations (3–6 months) show no significant increase in events but reduce bleeding.
4. Alternative Approaches:
• Some trials suggest stopping aspirin and continuing P2Y12 inhibitors (e.g., ticagrelor).
• Trials:
• SMART-CHOICE: clopidogrel after 3 months.
• STOPDAPT-2: clopidogrel after 1 month.
• TWILIGHT: ticagrelor monotherapy after 3 months.
5. Recent Trials:
• HOST-BR: 1 month vs 3 vs 12 months DAPT based on bleeding risk.
• High bleeding risk: 1 month increased events.
• Low bleeding risk: 3 months reduced bleeding, no increase in events.
• SMART-CHOICE 3: clopidogrel vs aspirin after standard DAPT; clopidogrel reduced events.
6. Ethnic and Regional Variations:
• Korean and East Asian populations show different responses (e.g., better tolerance to clopidogrel).
• Results may not generalize globally.
7. Guideline Position – 2025 ACC/AHA ACS Guidelines:
• Still recommend 12 months DAPT (Class 1A) unless high bleeding risk.
• Alternatives:
• Ticagrelor monotherapy after 1 month (Class 1A).
• Switch to clopidogrel or monotherapy (Class 2B).
8. Practical Realities:
• Clinical inertia and fear of thrombosis contribute to default 12-month use.
• Primary care often defers to cath lab reports recommending full-year DAPT.
9. Conclusion:
• No high-quality evidence has ever definitively shown that 12 months is superior.
• Shorter DAPT durations may be equally effective and safer for many patients.
• Clinical decisions should be personalized based on ischemic vs bleeding risk.
Link: Medscape article
