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DAPT De-escalation — EECC MCQ

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ModerateCoronary Artery DiseaseDAPT De-escalationEECC

A 62-year-old man is 12 months post-ACS treated with PCI and DES. He is on aspirin 75 mg and ticagrelor 90 mg bd. He has had no further ischaemic events and no bleeding. His cardiologist considers de-escalation of antiplatelet therapy. Which strategy is supported by recent evidence?

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Correct answer: C — De-escalate from ticagrelor to clopidogrel

DAPT de-escalation from a potent P2Y12 inhibitor (ticagrelor/prasugrel) to clopidogrel after 1-3 months is supported by the TOPIC and HOST-REDUCE-POLYTECH-ACS trials, which showed reduced bleeding without increased ischaemic events. The 2023 ESC ACS Guidelines include guided de-escalation (using platelet function testing or genotyping) as a Class IIb recommendation. Alternatively, P2Y12 monotherapy (dropping aspirin after 1-3 months of DAPT) is supported by the TWILIGHT, TICO, and STOPDAPT-2 ACS trials (Class IIa). The optimal strategy depends on the individual's ischaemic vs bleeding risk balance.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes: https://bnf.nice.org.uk/