Vol.:(0123456789) American Journal of Cardiovascular Drugs https://doi.org/10.1007/s40256-020-00430-0 REVIEW ARTICLE Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI Ali Ayoub 1  · Karnika Ayinapudi 1  · Ahmed Al‑Ogaili 2  · Muhammad Siyab Panhwar 1  · Wael Dakkak 3  · Thierry LeJemtel 1 © Springer Nature Switzerland AG 2020 Abstract The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controver- sial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12 months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still beneft from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1–3 months reduces bleeding rates without signifcantly increasing ischemic event rates. These trials also sug- gested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice. Key Points The duration of dual antiplatelet therapy (DAPT) should be individualized according to the patient’s ischemic and bleeding risks. After percutaneous coronary intervention, 1–3 months of DAPT and long-term P2Y12 receptor antagonist therapy provide a safe balance between stent thrombosis (ST) and bleeding. Low risks of bleeding and ST were observed across all trials of short-term DAPT followed by therapy with a single P2Y12 receptor antagonist. Patients with a high risk of ST are underrepresented in most randomized controlled trials. * Ali Ayoub Aayoub1@tulane.edu 1 Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA 70112, USA 2 Department of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA 3 Department of Medicine, Southern Illinois University, Springfeld, IL, USA 1 Introduction Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (aspirin) and a platelet P2Y12 receptor antagonist is the standard of care for prevention of thrombus formation within a stent, i.e., stent thrombosis (ST), after percutaneous coro- nary intervention (PCI). Potent antithrombotic interventions with aspirin and anticoagulants reduce the likelihood of ST but increase bleeding risk [1, 2]. European Society of Car- diology (ESC) and American College of Cardiology/Ameri- can Heart Association (ACC/AHA) guidelines recommend DAPT for at least 6 and 12 months after PCI in patients with stable coronary artery disease (SCAD) or acute coro- nary syndrome (ACS), respectively, and a low bleeding risk [3, 4]. Shortening the duration of DAPT aims to lower the bleeding risk, especially in patients at low ST risk [5, 6]. A reduction in the total number of medications may also facili- tate adherence to guideline-directed therapy in patients with multiple comorbidities. Another issue besides the optimal duration of DAPT is whether to replace aspirin with P2Y12 inhibitors after DAPT [7–10]. We review past and present