Best Strategies for DAPT in ACS Patients

9 Sept 2023 • Dual Antiplatelet Therapy after ACS has been the focus of several studies however a definitive strategy is yet to be accepted.

Currently, a short course of DAPT followed by P2Y12 inhibitor monotherapy and De-escalation (either by switch or dose reduction) are the two strategies favoured by US and European guidelines (either by switch or dose reduction).

Genotype and platelet function testing can help guide treatment decisions, however access to these technologies is limited by reasons like cost and expertise.

Therefore, a meta-analysis was conducted to separate out the DAPT strategies without involving genotyping or platelet function testing.

32 RCTs were included in this analysis which encompassed 103,497 ACS patients, who had been treated using one of the following strategies:

  • Standard DAPT with clopidogrel, prasugrel (standard/low dose), or ticagrelor for 12 months
  • Extended DAPT for at least 18 months
  • Short DAPT of no more than 6 months followed by P2Y12 inhibitor or aspirin monotherapy
  • 12 months of DAPT with unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitor or clopidogrel at 1 month
  • Guided DAPT with genotype or platelet function tests

The results revealed:

  • Unguided de-escalation strategy was the safest and most effective strategy in reducing major adverse cardiovascular events and major or minor bleeding.
  • Short DAPT followed by P2Y12 inhibitor was ranked the best for major bleeding and all-cause death.

However, experts believe that a well-powered, large-scale randomized trial comparing these strategies is warranted to definitively ascertain their relative efficacy and safety.

Source: AHA | Read full story"

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