Frontiers in medicine · 2026
Research progress on de-escalation strategies of dual antiplatelet therapy after acute coronary syndrome.
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Liu Xinyu, Liu Jingjing, Xu Chang
Аннотация
INTRODUCTION: Dual antiplatelet therapy (DAPT) is standard after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS), but prolonged DAPT increases bleeding risk, particularly in East Asian and high bleeding-risk (HBR) populations. De‑escalation strategies aim to balance ischaemic and bleeding risks.
METHODS: We conducted a structured literature search in PubMed, EMBASE, and the Cochrane Library (January 2018-April 2026) for randomized trials and key studies on DAPT de-escalation in ACS patients after PCI, using the Academic Research Consortium (ARC) tripartite classification framework.
RESULTS: Strong evidence supports discontinuation-based strategies: 3-month (TICO, TWILIGHT, SMART-CHOICE) and 1-month (ULTIMATE-DAPT, T-PASS, TARGET-FIRST) DAPT followed by P2Y12 inhibitor monotherapy reduce bleeding without increasing ischaemic events in selected patients. MASTER-DAPT established 1-month DAPT safety in HBR patients. However, very early aspirin withdrawal (within 4 days, NEO-MINDSET) failed non-inferiority for ischaemic outcomes, and clopidogrel monotherapy after 1-month DAPT was associated with higher ischaemic risk (STOPDAPT-2 ACS). Drug‑intensity de-escalation (e.g., ticagrelor-to-clopidogrel switching) and guided strategies using genotyping or platelet‑function testing show promise but require further validation.
CONCLUSION: Individualized DAPT de-escalation, guided by dynamic risk assessment using PRECISE‑DAPT and ARC-HBR criteria, optimizes net clinical benefit. Ticagrelor monotherapy after at least 1 month of DAPT is preferred over clopidogrel in ACS. Future research should focus on precision antithrombotic strategies in Chinese populations and high‑risk subgroups.
METHODS: We conducted a structured literature search in PubMed, EMBASE, and the Cochrane Library (January 2018-April 2026) for randomized trials and key studies on DAPT de-escalation in ACS patients after PCI, using the Academic Research Consortium (ARC) tripartite classification framework.
RESULTS: Strong evidence supports discontinuation-based strategies: 3-month (TICO, TWILIGHT, SMART-CHOICE) and 1-month (ULTIMATE-DAPT, T-PASS, TARGET-FIRST) DAPT followed by P2Y12 inhibitor monotherapy reduce bleeding without increasing ischaemic events in selected patients. MASTER-DAPT established 1-month DAPT safety in HBR patients. However, very early aspirin withdrawal (within 4 days, NEO-MINDSET) failed non-inferiority for ischaemic outcomes, and clopidogrel monotherapy after 1-month DAPT was associated with higher ischaemic risk (STOPDAPT-2 ACS). Drug‑intensity de-escalation (e.g., ticagrelor-to-clopidogrel switching) and guided strategies using genotyping or platelet‑function testing show promise but require further validation.
CONCLUSION: Individualized DAPT de-escalation, guided by dynamic risk assessment using PRECISE‑DAPT and ARC-HBR criteria, optimizes net clinical benefit. Ticagrelor monotherapy after at least 1 month of DAPT is preferred over clopidogrel in ACS. Future research should focus on precision antithrombotic strategies in Chinese populations and high‑risk subgroups.