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Войти в исследования Cardiovascular revascularization medicine : including molecular interventions · 2026
Expert perspectives on de-escalation of antiplatelet therapy - Beyond the Guidelines: Insights from the Cardiovascular Research Technologies 2026 meeting.
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Galo Jason, Granillo Matías Rodríguez, Rubio Pablo M, Mhaimeed Omar, Kastrati Adnan, Kaul Sanjay, Baber Usman, Gibson C Michael, Marmagkiolis Konstantinos, Kesarwani Manoj, Ben-Dor Itsik, Waksman Ron
Аннотация
INTRODUCTION: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor remains foundational following percutaneous coronary intervention (PCI), yet prolonged exposure carries cumulative bleeding risk. Growing evidence supports shorter DAPT durations followed by P2Y12 inhibitor monotherapy, prompting re-evaluation of when, how, and with which agent to de-escalate. Despite evolving data, significant gaps and guideline divergence persist.
METHODS: An expert panel convened at the 2026 Cardiovascular Research Technologies (CRT) conference synthesized contemporary evidence on antiplatelet de-escalation after PCI. This narrative state-of-the-art review prioritized randomized controlled trials, individual patient data meta-analyses, and current ACC/AHA and ESC guidelines. Evidence identification was informed by author expertise and structured review of landmark trials; a formal systematic search was not performed.
RESULTS: Key areas of convergence and controversy were identified across six domains: choice of single antiplatelet therapy (SAPT) following DAPT, optimal timing of de-escalation, the preferred P2Y12 inhibitor for monotherapy, the evidentiary basis for guideline recommendations, long-term SAPT beyond one year, and antithrombotic management in patients with concomitant atrial fibrillation. The panel found strong evidence favoring P2Y12 inhibitor monotherapy, preferably clopidogrel, over aspirin as post-DAPT maintenance therapy, and supported a de-escalation window of 1-3 months after PCI. Methodological limitations of existing non-inferiority trials were identified as barriers to assigning the highest evidence classification to ticagrelor monotherapy. In patients with atrial fibrillation, early aspirin discontinuation with continuation of a direct oral anticoagulant plus clopidogrel was endorsed as the preferred strategy.
CONCLUSIONS: The evidence supports a fundamental shift from traditional "aspirin for life" paradigms toward individualized, P2Y12-based de-escalation strategies following PCI. Although ticagrelor monotherapy is reasonable after 1-3 months of DAPT in select patients, expert consensus was not achieved on the level of recommendation endorsed by the 2025 ACC/AHA guidelines. Future research should address high-risk subgroups, refine genotype-guided approaches, and evaluate the long-term comparative effectiveness of available de-escalation strategies.
METHODS: An expert panel convened at the 2026 Cardiovascular Research Technologies (CRT) conference synthesized contemporary evidence on antiplatelet de-escalation after PCI. This narrative state-of-the-art review prioritized randomized controlled trials, individual patient data meta-analyses, and current ACC/AHA and ESC guidelines. Evidence identification was informed by author expertise and structured review of landmark trials; a formal systematic search was not performed.
RESULTS: Key areas of convergence and controversy were identified across six domains: choice of single antiplatelet therapy (SAPT) following DAPT, optimal timing of de-escalation, the preferred P2Y12 inhibitor for monotherapy, the evidentiary basis for guideline recommendations, long-term SAPT beyond one year, and antithrombotic management in patients with concomitant atrial fibrillation. The panel found strong evidence favoring P2Y12 inhibitor monotherapy, preferably clopidogrel, over aspirin as post-DAPT maintenance therapy, and supported a de-escalation window of 1-3 months after PCI. Methodological limitations of existing non-inferiority trials were identified as barriers to assigning the highest evidence classification to ticagrelor monotherapy. In patients with atrial fibrillation, early aspirin discontinuation with continuation of a direct oral anticoagulant plus clopidogrel was endorsed as the preferred strategy.
CONCLUSIONS: The evidence supports a fundamental shift from traditional "aspirin for life" paradigms toward individualized, P2Y12-based de-escalation strategies following PCI. Although ticagrelor monotherapy is reasonable after 1-3 months of DAPT in select patients, expert consensus was not achieved on the level of recommendation endorsed by the 2025 ACC/AHA guidelines. Future research should address high-risk subgroups, refine genotype-guided approaches, and evaluate the long-term comparative effectiveness of available de-escalation strategies.