Research progress on de-escalation strategies of dual antiplatelet therapy after acute coronary syndrome

Abstract

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.