Is 12 Months of Dual Antiplatelet Therapy (DAPT) Still Justified?
🔍 Is 12 Months of Dual Antiplatelet Therapy (DAPT) Still Justified?
Source: theheart.org on Medscape – May 12, 2025 | Commentary by Dr. Christopher Labos
🩺 Background:
• A full year of DAPT after stenting became standard practice following the CURE trial (2001), despite limited evidence on the optimal duration.
• Later trials (TRITON-TIMI 38, PLATO) supported DAPT but did not evaluate a 12-month regimen directly.
• Advances in stents and therapies question the relevance of old data.
⚖ Ischemic vs Bleeding Risk:
• Longer DAPT (>12 months) may reduce ischemic events but increases bleeding (seen in DAPT trial and meta-analyses).
• Shorter DAPT durations (1–6 months) often yield similar outcomes with less bleeding, especially in low-risk patients.
🧪 Key Trials Challenging the 12-Month Norm:
• SMART-CHOICE: 3 months DAPT then clopidogrel = safe.
• STOPDAPT-2: 1 month DAPT then clopidogrel = reduced bleeding.
• TWILIGHT: Ticagrelor monotherapy after 3 months = safe in high-risk patients.
• STOPDAPT-3: Aspirin-free strategy with low-dose prasugrel = feasible, but less applicable due to dosing concerns.
• HOST-BR (ACC 2025):
• High bleeding risk: 1 month DAPT = more events.
• Low bleeding risk: 3 months DAPT = less bleeding, no extra ischemic risk.
• SMART-CHOICE 3: After completing 6–12 months DAPT, monotherapy with clopidogrel reduced MAACE over 3 years (vs aspirin).
🌍 Ethnicity and Therapy:
• Many trials conducted in East Asia; clopidogrel preferred due to bleeding risk.
• Applicability to other ethnicities (e.g., Western populations) remains uncertain.
📘 Guideline Status (2025 ACS):
• Still recommend 12 months DAPT (Class 1A) unless high bleeding risk.
• Allow shorter DAPT followed by:
• Ticagrelor monotherapy after 1 month (Class 1A).
• Switching to clopidogrel (Class 2B).
• Any monotherapy after 1 month (Class 2B).
🧠 Key Messages:
• The 12-month DAPT standard was never directly proven to be superior.
• Modern data supports shorter, personalized DAPT durations.
• Clinical inertia, habit, and fear of stent thrombosis maintain the 12-month mindset.
• Primary care may hesitate to deviate from interventional cardiologist recommendations.
