Antiplatelet and Anticoagulant Therapy Guidelines

Introduction to Antiplatelet Therapy

The American College of Chest Physicians recommends dual antiplatelet therapy for acute coronary syndromes and post-stent placement, while single antiplatelet therapy is preferred for established coronary artery disease beyond one year after an acute event 1, 2, 3

The American College of Chest Physicians suggests low-dose aspirin (75-100 mg daily) for persons aged 50 years or older without symptomatic cardiovascular disease (Grade 2B) 3, 4
The European Heart Journal states that the benefit of aspirin in primary prevention is most pronounced when taken over 10 years, with a slight reduction in total mortality 3
The European Heart Journal recommends against aspirin for primary prevention in patients with diabetes at moderate cardiovascular risk 5
The American College of Chest Physicians recommends long-term SAPT with either aspirin (75-100 mg daily) or clopidogrel (75 mg daily) for patients with established CAD (Grade 1A) 2, 3
The American College of Chest Physicians prefers SAPT over dual antiplatelet therapy in patients with established CAD (Grade 2B) 2, 3
After 12 months following an acute coronary syndrome, the American College of Chest Physicians recommends SAPT over continued dual antiplatelet therapy (Grade 1B) 1, 3

For patients in the first year after acute coronary syndrome without PCI, the American College of Chest Physicians recommends DAPT with ticagrelor 90 mg twice daily plus low-dose aspirin or clopidogrel 75 mg daily plus low-dose aspirin over single antiplatelet therapy (Grade 1B) 3
The American College of Chest Physicians suggests ticagrelor 90 mg twice daily plus low-dose aspirin over clopidogrel 75 mg daily plus low-dose aspirin (Grade 2B) 3
For the first month after bare-metal stent placement, the American College of Chest Physicians recommends DAPT with aspirin 75-325 mg daily and clopidogrel 75 mg daily (Grade 1A) 1, 6
For months 2-12 after bare-metal stent placement, the American College of Chest Physicians recommends DAPT with low-dose aspirin 75-100 mg daily and clopidogrel 75 mg daily (Grade 2C) 1, 6
After 12 months after bare-metal stent placement, the American College of Chest Physicians recommends switching to SAPT (Grade 1B) 1, 6
For the first 3-6 months after drug-eluting stent placement, the American College of Chest Physicians recommends DAPT with aspirin 75-325 mg daily and clopidogrel 75 mg daily (Grade 1A) 1, 6
For months 4/7-12 after drug-eluting stent placement, the American College of Chest Physicians recommends continuing DAPT with low-dose aspirin 75-100 mg and clopidogrel 75 mg daily (Grade 2C) 1, 6
After 12 months after drug-eluting stent placement, the American College of Chest Physicians recommends switching to SAPT (Grade 1B) 1, 6

For patients with anterior MI with LV thrombus or high risk for LV thrombus and bare-metal stent placement, the American College of Chest Physicians recommends triple therapy with warfarin (INR 2.0-3.0), low-dose aspirin, and clopidogrel 75 mg daily for the first month (Grade 2C) 1, 7, 6
For patients with anterior MI with LV thrombus or high risk for LV thrombus and drug-eluting stent placement, the American College of Chest Physicians recommends triple therapy with warfarin (INR 2.0-3.0), low-dose aspirin, and clopidogrel 75 mg daily for the first 3-6 months (Grade 2C) 1, 7, 6

For patients on DAPT with aspirin and clopidogrel who develop bleeding, the American College of Chest Physicians recommends continuing aspirin and withholding clopidogrel 8
For patients with drug-eluting coronary stents, the American College of Chest Physicians suggests resuming P2Y12 receptor inhibitor preferably within 5 days after endoscopic hemostasis 8
For patients on warfarin with life-threatening bleeding and INR above 2.5, the American College of Chest Physicians recommends administering 4-factor prothrombin complex concentrate plus low-dose vitamin K 8