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International guidelines recommend the use of aspirin treatment immediately and indefinitely in coronary patients. The optimal time to start and the duration of dual antiplatelet therapy (DAPT; aspirin plus a P2Y12 inhibitor) have not been clearly established. Recent clinical trials have provided important new information allowing for evidence-based decisions regarding timing of initiation and duration of DAPT. The benefit-to-risk ratio of DAPT pre-treatment appears to depend on the type of acute coronary syndrome, the time until angiography, and the onset of action of the drug. In stable patients undergoing percutaneous coronary intervention with the latest generation drug-eluting stents, patients should be treated for at least ∼6 months. Shorter courses of therapy may be necessary when special conditions occur (e.g. surgery; oral anticoagulation). Longer courses of therapy may be reasonable in patients at low bleeding risk who are tolerating DAPT well. For patients with ACS, prolonged DAPT is beneficial and therefore reasonable as long as the patient is tolerating the therapy. Individualized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk-benefit to the patient according to changes in his/her clinical profile.

Oral dual antiplatelet therapy: what have we learnt from recent trials?