We also identify current gaps in the evidence, which represent areas for future research (Box 2). We summarize the evidence base for these two approaches to treatment, provide guidance on the assessment of ischaemic and bleeding risks, and make recommendations to help clinicians to optimize these approaches to DAPT for individual patients (Box 1). In this Consensus Statement, we refer to shortening of DAPT duration (also known as abbreviation of DAPT), in which DAPT is curtailed before the standard 12 months and treatment is continued with a single antiplatelet agent, either aspirin or a P2Y 12 inhibitor (clopidogrel, prasugrel or ticagrelor), and to de-escalation of DAPT intensity, in which treatment is switched from conventional doses of the more potent P2Y 12 inhibitors (prasugrel or ticagrelor) to either clopidogrel or reduced-dose prasugrel. Therefore, we convened an international panel of experts to produce a Consensus Statement to guide clinicians when identifying patients who are suitable for abbreviation or de-escalation of DAPT and to improve clinical outcomes by maintaining efficacy while reducing bleeding. To date, no position documents or guidelines have been published that summarize the available options for abbreviation or de-escalation of DAPT nor the evidence base supporting the various strategies. The existing European and North American guidelines on the management of ST-segment elevation myocardial infarction (STEMI) 2, 4, non-ST-segment elevation ACS 1, 5 and PCI 3, 6 only loosely cover options for antithrombotic therapy. Increased awareness of the prognostic importance of bleeding has prompted the investigation of strategies to de-escalate DAPT and identify a strategy balancing thrombotic and bleeding risks. Although DAPT reduces the risk of ischaemic events after ACS, it substantially increases the risk of bleeding 7, 8. The current ‘standard-of-care’ dual antiplatelet therapy (DAPT) for patients with ACS undergoing PCI, according to international guidelines, comprises aspirin combined with a potent P2Y purinoceptor 12 (P2Y 12) inhibitor, namely prasugrel or ticagrelor 1, 2, 3, 4, 5, 6. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.Īntiplatelet therapy is central to the management of acute coronary syndromes (ACS) in patients undergoing percutaneous coronary intervention (PCI). However, these two strategies have not yet been compared in a head-to-head clinical trial. Abbreviation of DAPT duration after 1–6 months, followed by monotherapy with aspirin or a P2Y 12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk.

De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y 12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration.

Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding.

Lip ORCID: /0000-0002-7566-1626 29, 30, 31Ĭonventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y 12) inhibitor (prasugrel or ticagrelor) for 12 months. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis

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