Redefining Dual Antiplatelet Strategies After Acute Coronary Syndrome: Insights from Recent RCTs

For nearly two decades, 12 months of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been the standard recommendation. Recent evidence suggests that abbreviated DAPT durations may reduce bleeding without compromising ischemic protection in selected patients. This review synthesizes randomized controlled trials, meta-analyses, and guideline updates published between 2023 and 2025, evaluating abbreviated DAPT strategies after ACS with percutaneous coronary intervention. Immediate aspirin withdrawal after PCI increased early stent thrombosis in NEO-MINDSET and STOPDAPT-3. One-month DAPT followed by ticagrelor monotherapy reduced bleeding without increasing ischemic events in ULTIMATE-DAPT and T-PASS. Three-month strategies demonstrated the most consistent safety profile, with TWILIGHT showing 50% bleeding reduction without increased death, myocardial infarction, or stroke (noting that TWILIGHT included 35% chronic coronary syndrome patients). Clopidogrel monotherapy after abbreviated DAPT increased myocardial infarction in STOPDAPT-2 ACS, highlighting the importance of potent P2Y12 inhibition. Meta-analyses confirmed bleeding reductions with early P2Y12 inhibitor monotherapy across broader populations, though benefits were more pronounced in East Asian cohorts. Abbreviated DAPT strategies offer personalized alternatives to standard 12-month therapy. Three-month DAPT followed by ticagrelor monotherapy represents a reasonable and evidence-supported strategy in selected patients with ACS. Risk stratification tools and individual patient factors should guide therapy duration decisions.