Dual antiplatlet therapy de escalation in stabilized mayocardial infarction with high ischemic risk

Abstract

Objective: To evaluate the safety and efficacy of de-escalating DAPT in stabilized myocardial infarction patients categorized as high ischemic risk based on clinical and angiographic criteria.

Methods: This prospective, comparative study included patients with ST-elevation and non-ST-elevation myocardial infarction who underwent successful percutaneous coronary intervention (PCI) and remained event-free for at least 1 month post-intervention. Patients were stratified based on ischemic risk and randomly assigned to either continued standard DAPT (aspirin + ticagrelor/prasugrel) or de-escalated DAPT (aspirin + clopidogrel). Primary outcomes included major adverse cardiovascular events (MACE), while secondary outcomes assessed bleeding complications using the BARC criteria over a 12-month follow-up.

Results: Among 300 high ischemic risk patients, 150 were assigned to continued potent DAPT and 150 to de-escalated DAPT. MACE occurred in 8.0% of the de-escalated group compared to 6.7% in the standard group (p=0.62). However, clinically relevant bleeding was significantly lower in the de-escalation arm (4.0% vs. 11.3%, p=0.01). Subgroup analysis showed consistent findings across diabetic and multi-vessel disease cohorts.

Conclusion: De-escalation of DAPT in stabilized myocardial infarction patients with high ischemic risk appears to be a safe strategy with a significantly lower risk of bleeding and without a substantial increase in ischemic events. These findings support a more individualized, risk-adapted approach to DAPT duration and intensity.