Dual anti-platelet therapy (DAPT) with aspirin and a P2Y12
inhibitor (clopidogrel, prasugrel, and ticagrelor) is a mainstay in the
therapy of patients who undergo percutaneous coronary intervention (PCI) with either drug-eluting stents (DES) or bare-metal stents
(BMS). We all get weekly or even daily communications from referring physicians, surgeons, or patients as to how long to stay on DAPT
after DES or when can DAPT therapy be interrupted for a patient
undergoing non-cardiac surgery. Such decisions can have significant implications on quality improvement and patient safety. This
Tip-of-the-Month (TOTM) will summarize new recommendations
on optimal DAPT duration and decision making tools, based on
recently published focused guideline updates and systematic reviews.
Now would be a good time to
find a quiet place to sit, put your
feet up, have a cup of coffee, and
review the TOTM points – then
be inspired to read the entire
document in the above link and
The following points cover
what is new in the topic of post
PCI DAPT, especially with the
use of DES.
1. Updated recommendations
for DAPT duration in patients
• Optimal DAPT duration in
patients who get a DES for
stable ischemic heart disease is
at least 6 months, as opposed
to at least 12 months in the
• Optimal DAPT duration in patients who get a DES for acute
coronary syndrome (ACS),
which includes non-ST elevation myocardial infarction
(NSTE-ACS) or ST elevation
myocardial infarction (
STE-MI) is 12 months, unchanged
from previous guidelines.
See Flow Diagram and Arrows
in Figure 1
2. Updated recommendations regarding interruption of DAPT in
patients with DES undergoing surgery:
• Interruption of DAPT before 3 months after DES is harmful.
• Interruption of DAPT may be considered between 3-6 months
after DES, if the risk of delaying surgery outweighs the risk of
• Interruption or discontinuation of DAPT 6 months after DES is
• If at all possible, low dose aspirin should be continued if the
P2Y12 agent is interrupted or discontinued
See Flow Diagram and Arrows from Figure 2.
Michael A. Kutcher, MD, FSCAI
FIGURE 1 – TREATMENT ALGORITHM FOR DURATION OF P2Y12 INHIBITOR THERAPY IN PATIENTS TREATED WITH PCI.
Reproduced from Levine GN et al. J Am Coll Cardiol 2016; 68:1082-115
Duration of Dual Anti-Platelet Therapy After Percutaneous Coronary
Intervention With Drug-Eluting Stents