Antiplatelet Modulation Strategies After PCI in Patients Without an Indication for Oral Anticoagulation

Dual antiplatelet therapy (DAPT) is central to the prevention of thrombotic complications after percutaneous coronary intervention (PCI). However, its optimal composition and duration are not uniform across all settings. Both ischemic and bleeding risks peak early after PCI, although their relative balance changes dynamically over time. This has shifted contemporary practice from standard DAPT regimens toward modulation of antiplatelet therapy by means of de-escalating and escalating the intensity of platelet inhibition tailored to clinical risk, procedural complexity, medication adherence, and time from PCI. In this narrative review, we examine randomized evidence on de-escalation and escalation antiplatelet strategies in patients undergoing PCI. De-escalation may be achieved through antiplatelet discontinuation, dose reduction, or switching. Among these approaches, aspirin withdrawal followed by P2Y12 inhibitor monotherapy with ticagrelor has the strongest evidence, particularly after an initial event-free period. Guided and unguided switching strategies may further refine treatment in selected patients. Conversely, escalation through increased doses, prolonged or additional antiplatelet therapy, or switching to more potent P2Y12 inhibition may be considered in patients in whom residual ischemic risk outweighs bleeding risk. Contemporary European and American guidelines increasingly reflect this risk-adapted approach. In conclusion, antiplatelet therapy following PCI should not be considered a “one size fits all” approach, but rather a strategy that needs to be tailored according to the patient’s risk profile that may need adjustments during the course of the patient’s follow-up.