Dual antiplatelet therapy in patients with an acute coronary syndrome: up to 12 months and beyond

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂-receptor antagonist plays a critical role in secondary prevention after an acute coronary syndrome (ACS). The use of DAPT lowers recurrent ischaemic events, including stent thrombosis, at the expense of bleeding complications when compared with aspirin alone. Based on early studies, a 12-month course of DAPT post-ACS has been recommended in the guidelines for years. A growing body of clinical trial data suggests that in general, patients with a biomarker positive ACS at low risk of bleeding who have tolerated DAPT well should continue beyond 12 months, with periodic reassessment of their bleeding risks. For patients at high risk of bleeding or with significant bleeding events during the initial year of DAPT, a shorter course would be recommended, particularly if second generation drug-eluting stents have been used. Thus, the decision to extend or shorten the duration of DAPT needs to be individualized based on the patient’s ischaemic and bleeding risks, including during the initial year of therapy. For most ACS patients, this will mean continuing DAPT beyond a year.