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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline January 18, 2022 Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 e70 CLINICAL STATEMENTS AND GUIDELINES 14 PHARMACOTHERAPY IN PATIENTS AFTER REVASCULARIZATION 14.1 Pharmacotherapy for Risk Factor Control in Patients After Revascularization Patients undergoing coronary revascularization require aggressive secondary preventive measures, including lifestyle modifications and medications for control of cholesterol, blood sugar, and blood pressure, as well as antiplatelet therapies. A detailed discussion of the pharmacotherapies used for secondary prevention after revascularization and the lifestyle measures used to optimize heart health are beyond the scope of the present guideline and are discussed in more detail elsewhere.1-4 This section will focus on the therapies that are especially relevant to patients undergoing revascularization. 14.2 Dual Antiplatelet Therapy in Patients After PCI Recommendation for Dual Antiplatelet Therapy in Patients After PCI Referenced studies that support the recommendation are summarized in Online Data Supplement 44. COR LOE Recommendation 2a A 1. In selected patients undergoing PCI, shorterduration DAPT (1–3 months) is reasonable, with subsequent transition to P2Y12 inhibitor monotherapy to reduce the risk of bleeding events.1-4 Synopsis After PCI, the use of DAPT prevents stent thrombosis and reduces ischemic events at the cost of increased bleeding.5 Pooled data have demonstrated less bleeding with shorter-term DAPT (3–6 months) and fewer ischemic events (including stent thrombosis) with longerterm DAPT (>12 months)5 (Figure 7). The 2016 guideline focused update on duration of DAPT6 highlights the importance of balancing ischemic and bleeding risk when DAPT is considered and provides recommendations for short and prolonged DAPT followed by aspirin monotherapy after revascularization. Since the release of those guidelines, more recent trials have been published.1-4,7 For this reason, additional recommendations for DAPT are provided. These recommendations should act as a supplement to the prior guideline focused update. Given the multiplicity of possible antiplatelet regimens available for use after revascularization, clinicians should weigh the risks of bleeding and recurrent ischemia when determining the choice of DAPT. Recommendation-Specific Supporting text 1. Since the 2016 guideline focused update, 5 large trials have tested a strategy of shorter-duration DAPT followed by P2Y12 inhibitor monotherapy after PCI.1-4,7 DAPT durations ranged from 1 month3,7 to 3 months.1,2,4 In aggregate, these data support a shorter course of DAPT followed by P2Y12 monotherapy, with a reduction in bleeding events (when compared with standard DAPT) and equivalent rates of ischemic events. Most supported clopidogrel and ticagrelor monotherapy, but prasugrel monotherapy was included in 1 trial.2 A meta-analysis of the duration of DAPT incorporating these 5 trials reported a 40% reduction in the rate of major bleeding events with shorter-term DAPT followed by P2Y12 monotherapy and no significant difference in MACE. The trials evaluating the use of shorter-duration DAPT followed by P2Y12 monotherapy were not powered to assess differences in stent thrombosis. These trials included few patients with STEMI. No trial has compared short-term DAPT followed by P2Y12 monotherapy with short-term DAPT followed by aspirin alone. 14.3 Antiplatelet Therapy in Patients After CABG Recommendations for Antiplatelet Therapy in Patients After CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 45. COR LOE Recommendations 1 A 1. In patients undergoing CABG, aspirin (100–325 mg daily) should be initiated within 6 hours postoperatively and then continued indefinitely to reduce the occurrence of SVG closure and adverse cardiovascular events.1-7 2b B-R 2. In selected patients undergoing CABG, DAPT with aspirin and ticagrelor or clopidogrel for 1 year may be reasonable to improve vein graft patency compared with aspirin alone.8-10 Synopsis The mechanisms warranting DAPT therapy in patients who have undergone CABG are distinct from those in patients who have had ACS and have undergone PCI. The pathophysiology of vein graft occlusion involves a different mechanism from that of native vessel disease with atherosclerosis, plaque rupture, or stent thrombosis. Additionally, a larger percentage of the coronary tree is bypassed with CABG in contrast to the focal lesions treated with PCI. Finally, surgical bleeding is more of a concern in the perioperative and immediate postoperative period following CABG. Observational and small randomized trials and meta-analyses of these studies support that DAPT after CABG improves vein graft patency, primarily among patients undergoing off-pump surgery and those with higher SYNTAX scores. The role of DAPT in patients who undergo CABG after ACS is addressed in the DAPT guideline.11 The role of prolonged DAPT for Downloaded from http://ahajournals.org by on October 7, 2026