Dual antiplatelet therapy: which drugs, which indications, which dosages and for how long?

Dual antiplatelet therapy combining aspirin plus a platelet ADP receptor antagonist has been a major therapeutic advance over the last twenty years. After implantation of coronary-artery stent, it has reduced the risk of acute thrombosis but with sometimes fatal consequences. After an acute coronary syndrome, dual antiplatelet therapy reduced the risk of major cardiovascular events and also mortality. Three platelet ADP receptor antagonists are currently available: clopidogrel, prasugrel and ticagrelor. After elective angioplasty, the combination of aspirin plus clopidogrel for 1 month after bare-metal stent (minimal duration) and between 6 and 12 months after implantation of a drug-eluting stent is the only validated therapeutic option. After an acute coronary syndrome, there is a choice between the three molecules in combination with aspirin but prasugrel and ticagrelor have demonstrated their superiority in comparison with clopidogrel. There is no data comparing prasugrel and ticagrelor. Treatment will be given for 1 year. No currently reported data justifies the continuation of dual antiplatelet therapy beyond 1 year.