ACC guidance explores antiplatelet therapies for the management of ASCVD
Major changes have occurred in recent years when it comes to cutting down on the widespread use use of aspirin. In fact, numerous clinical trials looking at potentially shortening the duration of dual antiplatelet therapy (DAPT) following revascularization have prompted the American College of Cardiology (ACC) to develop a new scientific statement on that very topic.[1]
The document, "Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease: 2026 ACC Scientific Statement," provides a detailed overview of current clinical evidence for the use of antiplatelet medications in the primary and secondary prevention and management of atherosclerotic cardiovascular disease (ASCVD). It includes a comparison of current clinical practice guideline–based recommendations, a summary of recent pivotal trials and a discussion of antiplatelet use in patients who may face an elevated bleeding risk. The document also looks at use of antiplatelet agents in different phenotypes of ASCVD as well as patients who are also taking antithrombotic medications.
"Antiplatelet medications have been fundamental to the management of ASCVD. However, recommendations for their use have evolved over the past decade," wrote Dharam J. Kumbhani, MD, chair of the writing committee and section chief and director of interventional cardiology at UT Southwestern Medical Center, and colleagues. "Aspirin remains the most widely used antiplatelet drug, but recent data do not support a benefit for primary prevention of ASCVD in unselected populations with routine aspirin use. Similarly, the evolution of drug-eluting stents, antiplatelet medications, and research on the optimal regimen and duration of dual antiplatelet therapy have altered evidence-based recommendations for use of antiplatelets in managing patients diagnosed with ASCVD."
Kumbhani et al. said antiplatelet medications remain powerful tools to prevent ischemic events, but there needs to be a balance between the risk of ischemia and the risk of bleeding. The group also emphasized that making these treatment decisions ultimately requires looking at each individual patient instead of just making general rulings on entire populations.
The evolution of DAPT therapy
The first-generation drug-eluting stents (DES) caused a significantly elevated risk of stent thrombosis (ST) compared with bare-metal stents, so earlier studies on DAPT duration focused on extending out DAPT therapy to avoid complications. These studies were also based on the use of clopidogrel as the primary P2Y12 inhibitor used at that time. But advances in stent technology, the increased use of intravascular imaging to guide percutaneous coronary intervention (PCI) and the routine use of more potent antiplatelet agents have resulted in attention shifting toward mitigating bleeding risk.
These concerns have prompted dozens of studies looking at shorter DAPT duration followed by aspirin monotherapy or a deescalation to P2Y12 inhibitor monotherapy. Current-generation DES designs using ultrathin stent struts and biodegradable polymers have also significantly reduced ST rates as low as 0.4% at 1 year and less than 1% at five years.
Reducing the duration of DAPT after PCI
The new statement incorporates more contemporary clinical data to recommend less DAPT and a wider use of monotherapy considering the much lower ST risks associated with modern stents. The authors considered data from several trials that evaluated abbreviated DAPT followed by P2Y12 inhibitor monotherapy.
The results of the TWILIGHT trial were highlighted, where high-risk patients who completed three months of DAPT with ticagrelor plus aspirin with no events were randomized to continue DAPT or switch to ticagrelor monotherapy.[2] Discontinuation of aspirin was found to significantly reduced bleeding BARC Types 2, 3, or 5 without increasing the risk of death, myocardial infarction or stroke.
The statement cites similar findings in the TICO (Ticagrelor Monotherapy After 3 Months),[3] T-PASS (Ticagrelor Monotherapy in Patients Treated With New-Generation DES for ACS),[4] and TARGET-FIRST (Evaluation of a Modified Anti-Platelet Therapy Associated With Low-dose DES Firehawk in Acute MI Patients Treated With Complete Revascularization Strategy)[5] trials. These studies used between one to three months of DAPT followed by ticagrelor or prasugrel monotherapy, which reduced major bleeding with comparable ischemic outcomes versus 12 months of DAPT.
Clopidogrel monotherapy was not found to be as effective during 12 months of DAPT in the primary composite ischemic and bleeding endpoints. The authors said clopidogrel was associated with a strong trend toward increased ischemic events.[6]
Based on this evidence, its is recommended using monotherapy with ticagrelor or prasugrel after one to three months of DAPT after PCI for acute coronary syndrome (ACS), but not using monotherapy of aspirin or clopidogrel unless the patient has a high bleeding risk.
Consensus recommendations on using aspirin
The statement shows that aspirin can be effective in the primary prevention of cardiovascular events, but it is associated with an increased risk of major bleeding. The authors also noted that the current lack of benefit with aspirin for primary prevention may be due to the use of other effective preventive strategies like statins.
Low-dose aspirin might be considered for the primary prevention of ASCVD events in adults ages 40-70 years who have a higher cardiovascular risk without an increased bleeding risk. However, the routine use of aspirin for prevention in those over age 70 year should be avoided.
The writing committee suggests the used of ASCVD calculators to better identify patients at high ischemic risk. If these patients are at low bleeding risk, aspirin may be considered for primary prevention. Use of aspirin in those with high-bleeding risk patients is associated with net harm regardless of calcium score or ASCVD risk, the authors concluded.
The scientific statement includes a summary of pivotal clinical trials, and compares current recommendations from ACC/AHA and European Society of Cardiology (ESC) clinical guidelines for ACS, chronic coronary disease and chronic coronary syndromes.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]