Perspective on the Choice and Duration of Dual Antiplatelet Therapy Recommendations in the 2025 Acute Coronary Syndrome Management Guideline

Q: What is the clinical evidence from this study?

Study design: Review. Population: Atrial fibrillation and percutaneous coronary intervention. Intervention: DOAC-based dual antithrombotic therapy (DAT) with early aspirin discontinuation vs. Prolonged triple antithrombotic therapy (TAT).

Dennis T. Ko; Rasha Kadem Al-Lamee; Behnood Bikdeli; David J. Cohen; James Louis Januzzi; Mitsuaki Sawano; Erica Sarah Spatz; Seng Chan You

doi:10.1016/j.jacc.2025.04.045

June 1, 2025Journal of the American College of CardiologyOpen Access

Perspective on the Choice and Duration of Dual Antiplatelet Therapy Recommendations in the 2025 Acute Coronary Syndrome Management Guideline

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Key Points

To critically review contemporary evidence and provide perspective on antithrombotic therapy choices, regimens, and durations for patients with atrial fibrillation undergoing percutaneous coronary intervention.
Synthesized randomized clinical trial evidence and guideline recommendations concerning combination antithrombotic therapies.
Evaluated regimens involving direct oral anticoagulants (DOACs), dual antiplatelet therapy (DAPT), and triple antithrombotic therapy (TAT).
Assessed competing temporal hazards between stent thrombosis, cardioembolism, and major bleeding complications.
Adding a single antiplatelet agent to oral anticoagulation increases bleeding risk by 20% to 60%, whereas triple antithrombotic therapy increases bleeding risk 2- to 3-fold.
Aspirin should generally be stopped at hospital discharge or within 1 week, continuing a DOAC plus clopidogrel for up to 12 months after acute coronary syndrome and up to 6 months after elective percutaneous coronary intervention.
Triple antithrombotic therapy may be extended up to 1 month only when ischemic risk is high and bleeding risk is acceptable, with clopidogrel remaining the preferred P2Y12 inhibitor over routine prasugrel or ticagrelor.

PICO

P

Population

Patients with atrial fibrillation undergoing percutaneous coronary intervention who require antithrombotic therapy.

I

Intervention / Comparator

DOAC-based dual antithrombotic therapy (DAT) with early aspirin discontinuation vs Prolonged triple antithrombotic therapy (TAT)

Limitations

Available risk stratification tools have modest predictive performance and fail to capture the dynamic nature of ischemic and bleeding risks.
Uncertainties persist regarding the optimal timing of aspirin withdrawal and transition to OAC monotherapy in patients at very high thrombotic or bleeding risk.
Patients with complex clinical profiles such as frailty, advanced age, or polypharmacy remain challenging to manage due to overlapping risks.

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Implication

May warrant limiting triple therapy duration in AF-PCI; extends prior RCT syntheses while leaving high-ischemic-risk extensions open.

Abstract

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Cite This Study

Ko et al. (2025) conducted a review in Atrial fibrillation and percutaneous coronary intervention. DOAC-based dual antithrombotic therapy (DAT) with early aspirin discontinuation vs. Prolonged triple antithrombotic therapy (TAT) was evaluated.

synapsesocial.com/papers/6ad2b5044c9c4fbb13a7edab https://doi.org/10.1016/j.jacc.2025.04.045

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Perspective on the Choice and Duration of Dual Antiplatelet Therapy Recommendations in the 2025 Acute Coronary Syndrome Management Guideline

Key Points

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Perspective on the Choice and Duration of Dual Antiplatelet Therapy Recommendations in the 2025 Acute Coronary Syndrome Management Guideline

Key Points

PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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