Antiplatelet Therapy in Acute Coronary Syndrome

Optimal DAPT Regimen

The American College of Cardiology recommends that all patients with ACS receive dual antiplatelet therapy consisting of aspirin plus a P2Y12 inhibitor for 12 months, regardless of whether they undergo PCI, receive medical management alone, or proceed to CABG 1, 2
Ticagrelor (180 mg loading dose, then 90 mg twice daily) plus aspirin 75-100 mg daily is the preferred first-line regimen for all ACS patients, applying to both STEMI and NSTEMI presentations, regardless of initial management strategy 1, 2
Prasugrel (60 mg loading dose, then 10 mg daily) plus aspirin is the alternative first-line option for P2Y12 inhibitor-naïve patients with ACS undergoing PCI, unless contraindications exist 1, 2
Clopidogrel (300-600 mg loading dose, then 75 mg daily) is reserved only for patients who cannot receive ticagrelor or prasugrel due to contraindications or need for oral anticoagulation 1, 2

The default DAPT duration is 12 months for all ACS patients who are not at high bleeding risk, regardless of ACS type, stent type, or completeness of revascularization 1, 2
For ACS patients with high bleeding risk, shortened DAPT duration of 6 months may be reasonable 1, 2

All ACS patients require anticoagulation in addition to antiplatelet therapy, irrespective of initial treatment strategy, with options including enoxaparin, bivalirudin, fondaparinux, and UFH 3

Prescribe a PPI to all patients on DAPT, as this is a Class I recommendation, with PPIs being superior to H2 receptor antagonists in preventing upper GI bleeding 1, 4
Use radial artery access over femoral access for PCI when performed by an experienced radial operator 1, 2
Maintain aspirin dose at 75-100 mg daily when combined with a P2Y12 inhibitor 1, 2

For ACS patients previously on clopidogrel, switch to ticagrelor early after hospital admission with a 180 mg loading dose, regardless of timing and loading dose of clopidogrel 2
Resume P2Y12 inhibitor therapy after CABG to complete 12 months of DAPT 1
For patients requiring long-term anticoagulation, discontinue aspirin 1-4 weeks after PCI and continue P2Y12 inhibitor, preferably clopidogrel rather than ticagrelor 2

Never discontinue DAPT prematurely, especially within the first month after stent placement, as this dramatically increases risk of stent thrombosis, MI, and death 1, 2
Never fail to prescribe a PPI with DAPT, as this simple intervention significantly reduces GI bleeding 1, 4
Never use clopidogrel as first-line therapy when ticagrelor or prasugrel are available and not contraindicated, as this represents suboptimal care 1, 2

Immediately discontinue GP IIb/IIIa inhibitors and/or heparin if thrombocytopenia <100,000/mL or >50% relative drop from baseline occurs, with platelet transfusion recommended for major active bleeding or severe thrombocytopenia (<10,000/mL) 5, 6