Personalized Antithrombotic Therapy After Percutaneous Coronary Intervention: A Systematic Review of Risk-Stratified Approaches.
Antithrombotic therapy after percutaneous coronary intervention (PCI) is shifting from fixed 12-month dual antiplatelet therapy (DAPT) to risk-stratified, patient-centered regimens. In this systematic review (80 studies; >330,000 patients), we compare personalized versus fixed DAPT strategies, evaluate abbreviated DAPT in high-bleeding-risk (HBR) populations, and evaluate bleeding and ischemic risk scores. Personalized strategies, including genotype-guided therapy, ultra-short DAPT (≤1 month) with P2Y12 monotherapy, and 3-month DAPT, substantially reduce bleeding (often by roughly 25%-65%); ischemic risk after de-escalation is heterogeneous across populations and strategies, with most trials showing neutrality and one (STOPDAPT-2 ACS) signaling increased myocardial infarction (MI) when aspirin was withdrawn after 1-2 months of clopidogrel-based DAPT in acute coronary syndrome (ACS). In HBR patients, 1 to 3-month DAPT followed by P2Y12 monotherapy lowers major bleeding by up to 65% and may reduce cardiovascular mortality, without increased MI or stent thrombosis in most trials, although ischemic signals varied by population and strategy. In atrial fibrillation, avoiding prolonged triple therapy reduces bleeding by approximately 30%. In ACS, prasugrel is favored over ticagrelor for ischemic outcomes; ARC-HBR, PRECISE-DAPT, and the newer PRECISE-HBR scores show moderate discrimination (c-statistic 0.64-0.75). Contemporary data therefore support replacing one-size-fits-all 12-month DAPT with risk-guided algorithms for post-PCI antithrombotic therapy.