Recommendation 1. We recommend DAPT with ASA 81 mg daily with either ticagrelor 90 mg BID or prasugrel 10 mg once daily over clopidogrel 75 mg once daily for 1 year (Strong Recommendation; High-Quality Evidence).
Recommendation 2. We recommend that, in patients who tolerate 1 year of DAPT without a major bleeding event and who are not at high risk of bleeding, DAPT should be extended beyond 1 year (Strong Recommendation; High-Quality Evidence for up to 3 years of treatment). After 1 year, we recommend a DAPT regimen of ASA 81 mg daily plus either ticagrelor 60 mg BID or clopidogrel 75 mg once daily (Strong Recommendation; High-Quality Evidence) or prasugrel 10 mg once daily (Weak Recommendation; Moderate-Quality Evidence).
Values and preferences. These recommendations place greater emphasis on reduction of major CV events and stent thrombosis vs an increase in bleeding complications.
Practical tip. Recommendations on duration of DAPT apply specifically to duration of P2Y12 inhibitor therapy. ASA should be continued indefinitely in most patients with CAD who are not receiving oral anticoagulant therapy.
Practical tip. Patients who have clinical or angiographic features for an increased risk of a thrombotic CV event might derive greater absolute benefit from extended DAPT beyond 1 year (Table 1).
Practical tip. Quantitative risk scores have been developed. These scores might help identify higher-risk patients with greater absolute benefit of extended DAPT (Table 3).
Practical tip. An ongoing assessment of bleeding and ischemic risk should be performed at least annually to determine whether DAPT should be continued.
Practical tip. Prasugrel should be avoided in patients with previous transient ischemic attack or stroke.
Practical tip. For patients who have a bleeding event during ticagrelor or prasugrel treatment, but for whom continuation of a P2Y12 agent is believed to be warranted, please refer to the de-escalation recommendations in section 2.3.
Practical tip. In patients with STEMI who receive fibrinolytic therapy, clopidogrel is currently the recommended P2Y12 inhibitor within the first 24 hours. A recent randomized trial showed a higher level of platelet inhibition with ticagrelor compared with clopidogrel.25 Ongoing trials are evaluating clinical outcomes with ticagrelor in this setting (ClinicalTrials.gov NCT02298088).