Ultrashort DAPT after ACS halves bleeding — if the monotherapy is a potent P2Y12 inhibitor

Design

Systematic review and meta-analysis of 10 randomised trials

Population

29,232 patients with ACS undergoing PCI

Primary outcome

MACCE, major bleeding and net adverse clinical events

Effect

MACCE HR 1.06 (95% CI 0.93–1.20); major bleeding HR 0.47 (0.35–0.64); ≤1-week DAPT or clopidogrel/aspirin monotherapy MACCE HR 1.37 (1.11–1.69)

A meta-analysis of 10 randomised trials pooled 29,232 patients with acute coronary syndrome undergoing PCI. It compared dual antiplatelet therapy of one month or less, followed by single antiplatelet therapy, with standard-duration DAPT.

Overall, ultrashort DAPT did not raise MACCE (HR 1.06) and roughly halved major bleeding (HR 0.47), giving a net clinical benefit. Two details matter more than the headline. The strategy changed the result: stopping DAPT at a week or less, or continuing on clopidogrel or aspirin, raised MACCE by about a third, while at least two weeks of DAPT followed by ticagrelor or prasugrel did not. And the ischaemic signal appeared in STEMI but not in NSTE-ACS.

For Indian practice, where clopidogrel is still the default P2Y12 inhibitor for many, this is a caution. Short DAPT works when the single agent that follows is potent. Bleeding reduction was also greater in East Asian patients, though South Asian patients were not reported separately.

• Keep at least two weeks of DAPT before de-escalating after ACS
• Use ticagrelor or prasugrel, not clopidogrel or aspirin, as monotherapy after very short DAPT
• Be more cautious about shortening DAPT after STEMI than after NSTE-ACS
• Document bleeding risk at discharge to justify the chosen duration

Why it matters

Short DAPT is safe only with the right monotherapy, which matters where clopidogrel is the usual choice.

Don't overread it

The STEMI and strategy differences come from comparing different trials, not from randomisation within one.

The statistics, in plain English

Major bleeding HR 0.47 (95% CI 0.35–0.64) is a halving with a tight interval. MACCE HR 1.06 (0.93–1.20) crosses 1, so no overall ischaemic harm was shown. But the net benefit estimate carries I² = 61%, meaning trials disagreed substantially. The strategy subgroups differ significantly (interaction P = 0.003), which is stronger than a typical subgroup claim, though it is still a comparison across trials rather than within them.

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