Optimal duration of dual antiplatelet therapy after PCI: integrating procedural complexity, bleeding risk and the acuteness of clinical presentation.

INTRODUCTION: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor constitutes the standard of care to prevent major adverse cardiac events in patients who undergo percutaneous coronary intervention (PCI) with drug-eluting stents (DES). However, the anti-ischemic benefits of DAPT are counterbalanced by an increased risk of hemorrhagic complications, which are known to be associated with increased morbidity and mortality. While the efficacy of DAPT in patients presenting with acute coronary syndrome (ACS) has been well established, the risk-benefit balance of DAPT in other subsets of patients remain controversial. As a result, multiple risk scores to inform optimal duration of DAPT have been developed recently for individuals with various degrees of coronary artery disease. Areas covered: Authors summarize the current evidence and guideline recommendations on the optimal duration and intensity of DAPT across the spectrum of coronary artery disease including those who undergo complex PCI and recapitulated the recently developed risk scores to inform clinical decision on the optimal duration of DAPT. Expert commentary: Clinical decision-making for upfront duration of DAPT after PCI with DES should consider the individual bleeding risk profile, the initial clinical presentation and the complexity of coronary stenting.