Reduce DAPT to 3 Months After MI (DUAL-ACS Trial)
Reduce DAPT to 3 Months After MI (DUAL-ACS Trial)
Source: Medscape, ESC Congress 2025 – September 11, 2025
1. Background
• Current guidelines: 12 months of DAPT after MI (Class 1A).
• Concern: prolonged DAPT increases bleeding and may even increase all-cause mortality.
2. Trial Design
• Randomized, real-world study in ~5,000 MI patients (Scotland).
• Compared 3 months DAPT → single antiplatelet vs 12 months DAPT.
• Most patients received aspirin + clopidogrel/ticagrelor.
3. Key Results
• All-cause mortality: lower with 3 months (2.7%) vs 12 months (3.4%), HR 0.78 (NS).
• CV death or nonfatal MI: similar (9.3% vs 8.9%).
• Major bleeding: less with 3 months (3.2% vs 4.0%), HR 0.78 (NS).
• Trial was underpowered (planned 17,000 but stopped at 5,000 due to COVID).
4. Interpretation
• Trends support shorter DAPT duration (less bleeding, possible mortality benefit).
• Consistent with meta-analyses and prior data.
• “Less is more” — prolonged DAPT may cause harm without added efficacy.
5. Guideline Implications
• Current ESC & AHA/ACC guidelines still recommend 12 months unless high bleeding risk.
• Experts suggest future guidelines should consider shorter DAPT or P2Y12 monotherapy strategies.
Take-home message:
While not statistically significant, DUAL-ACS adds real-world evidence that 3 months of DAPT post-MI may be enough — reducing bleeding and potentially lowering mortality — and calls into question the routine 12-month recommendation.
