Key result
Individualized DAPT de-escalation reduces bleeding without increasing ischemic risk in selected ACS patients.
Why the study?
Prolonged DAPT after PCI in ACS increases bleeding risk, particularly in East Asian and high bleeding-risk populations, motivating de-escalation strategies to balance ischaemic and bleeding risks.
Do dual antiplatelet therapy de-escalation strategies reduce bleeding without increasing ischaemic events in ACS patients after PCI?
Do dual antiplatelet therapy de-escalation strategies reduce bleeding without increasing ischaemic events in ACS patients after PCI?
Individualized DAPT de-escalation, particularly ticagrelor monotherapy after at least 1 month of DAPT, optimizes net clinical benefit by reducing bleeding without increasing ischemic risk in ACS patients post-PCI.
Supports 1-3 month DAPT de-escalation to P2Y12 monotherapy in selected ACS post-PCI patients; reinforces RCT evidence for lower bleeding without excess ischemia.
Introduction Dual antiplatelet therapy (DAPT) is standard after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS), but prolonged DAPT increases bleeding risk, particularly in East Asian and high bleeding-risk (HBR) populations. De‑escalation strategies aim to balance ischaemic and bleeding risks. Methods We conducted a structured literature search in PubMed, EMBASE, and the Cochrane Library (January 2018–April 2026) for randomized trials and key studies on DAPT de-escalation in ACS patients after PCI, using the Academic Research Consortium (ARC) tripartite classification framework. Results Strong evidence supports discontinuation-based strategies: 3-month (TICO, TWILIGHT, SMART-CHOICE) and 1-month (ULTIMATE-DAPT, T-PASS, TARGET-FIRST) DAPT followed by P2Y12 inhibitor monotherapy reduce bleeding without increasing ischaemic events in selected patients. MASTER-DAPT established 1-month DAPT safety in HBR patients. However, very early aspirin withdrawal (within 4 days, NEO-MINDSET) failed non-inferiority for ischaemic outcomes, and clopidogrel monotherapy after 1-month DAPT was associated with higher ischaemic risk (STOPDAPT-2 ACS). Drug‑intensity de-escalation (e.g., ticagrelor-to-clopidogrel switching) and guided strategies using genotyping or platelet‑function testing show promise but require further validation. Conclusion Individualized DAPT de-escalation, guided by dynamic risk assessment using PRECISE‑DAPT and ARC-HBR criteria, optimizes net clinical benefit. Ticagrelor monotherapy after at least 1 month of DAPT is preferred over clopidogrel in ACS. Future research should focus on precision antithrombotic strategies in Chinese populations and high‑risk subgroups.
No takes yet. Share an insight, caveat, or question.
Liu et al. (2026) conducted a review in Acute coronary syndrome. DAPT de-escalation strategies vs. Standard dual antiplatelet therapy was evaluated. Individualized DAPT de-escalation, particularly transitioning to ticagrelor monotherapy after at least 1 month of DAPT, reduces bleeding without increasing ischemic events in selected ACS patients.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: