Clinical decision-making on the duration and strategy of antithrombotic therapy in patients with chronic and acute coronary syndrome (CCS and ACS) after PCI is nowadays a major challenge.

There have been several developments in the field of antithrombotic strategies during the last recent years, including P2Y12 inhibitor monotherapy, addition of low-dose factor Xa inhibitor to antiplatelet therapy, de-escalation or escalation of P2Y12 inhibition guided by platelet function or genotype. Several scenarios have been observed with studies on DAPT duration. Some showed a reduction in bleeding without an increase ischemic events with shorter duration of DAPT compared to 12 months DAPT in patients with low risk of ischemic events. Other studies on longer duration of DAPT showed reduced ischemic events with extended DAPT up to 3 years without an increase in bleeding compared to 12 months DAPT in patients with DES or in those with an MI.

It can also be difficult to interpret results of clinical trials that use composite endpoints – a combination of ischemic events and major bleeding. The individual components of this composite endpoint can have different effects on mortality, morbidity and quality of life.

Furthermore, risk stratification to identify patients for specific treatment strategies is important and can be done by risk scores, platelet function testing and genotyping, all with advantages and disadvantages.

The topics covered in this clinical review are:

• Short DAPT followed by aspirin monotherapy
• Short DAPT followed by P2Y12 inhibitor monotherapy
• Extended DAPT
• Low-dose factor Xa inhibitor on top of antiplatelet therapy
• Risk stratification and risk scores
• Risk scores to be used at the time of PCI – The PRECISE-DAPT score
• Risk score to be used 12 months after PCI – The DAPT score
• Platelet function- or genotype-guided P2Y12 inhibitor therapy
• Patient-tailored antiplatelet therapy in daily practice

Find this article online at Eur Heart J Watch a video by Van der Sangen