What are the AHA/ACC guidelines on dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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In 2016, the ACC/AHA released updated guidelines on duration of dual antiplatelet therapy (DAPT) in patients with coronary artery disease. In this focused update, the term and acronym DAPT is used to specifically to refer to combination antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor).

Key recommendations for patients with NSTE-ACS or STEMI treated with DAPT are summarized below. [116]

Class I

For all patients treated with DAPT, a daily dose of aspirin 81 mg (range, 75 mg to 100 mg). (Level of evidence: B-R)

After implantation with a bare metal stent (BMS) or drug-eluting stent (DES), administer P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) for at least 12 months. (Level of evidence: B-R)

For patients who subsequently undergo coronary artery bypass grafting (CABG) after coronary stent implantation, resume P2Y12 inhibitor therapy postoperatively so that DAPT continues until the recommended duration of therapy is completed. (Level of evidence: C-EO)

In patients who undergo CABG, resume P2Y12 inhibitor therapy after CABG to complete 12 months of DAPT therapy. (Level of evidence: C-LD) 

Patients with STEMI treated with fibrinolytic therapy should be continue P2Y12 inhibitor therapy (clopidogrel) for a minimum of 14 days (Level of evidence: A) and, ideally, at least 12 months. (Level of evidence: C-EO)

Class IIa

After coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy. (Level of evidence: B-R)

After coronary stent implantation in patients who are not at high risk for bleeding complications and who do not have a history of stroke or transient ischemic attack (TIA), it is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 inhibitor therapy. (Level of evidence: B-R)

Class IIb

In patients treated with coronary stent implantation or fibrinolytic therapy who have tolerated DAPT without a bleeding complication and who are not at high bleeding risk, it may be reasonable to continue DAPT (clopidogrel, prasugrel, or ticagrelor) for longer than 12 months. (Level of evidence: A)

After DES implantation, patients who develop a high risk of bleeding, are at high risk of severe bleeding complications, or develop significant overt bleeding, it may be reasonable to discontinue P2Y12 inhibitor therapy after 6 months. (Level of evidence: C-LD)

Class III

Prasugrel should not be administered to patients with a prior history of stroke or TIA. (Level of evidence: B-R)

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