De-escalation or Abbreviation of Dual Antiplatelet Therapy in Acute Coronary Syndromes and PCI – Consensus Statements from an International Expert Panel on Coronary Thrombosis

Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes (ACS) undergoing percutaneous cardiovascular intervention comprises of aspirin with a potent P2Y12 inhibitor (ticagrelor or prasugrel) for 12 months. Whilst reducing ischaemic risk, this exposes patients to a significant risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitors prasugrel or ticagrelor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration, and the two approaches have not been compared in a head-to-head trial.
Nevertheless, use of either strategy requires an assessment of the individual’s ischaemic and bleeding risks. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and may be guided by platelet function testing or genotyping. Abbreviation of DAPT after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk.
Herein, we summarise the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risk, and provide consensus statements, from an international panel, to help guide clinicians to optimise these DAPT approaches for individual patients to improve outcomes.