Refining DAPT strategies after drug coated balloon angioplasty

The evolution of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) has been shaped by the continuous challenge of balancing ischaemic protection with bleeding risk. While prolonged DAPT confers thrombotic risk reduction, it invariably increases bleeding complications, which are themselves associated with adverse prognostic implications.1 This dilemma has prompted the exploration of de-escalation strategies—gradual tapering of antiplatelet intensity or duration—as a means of optimising patient outcomes. Currently, the concept of DAPT de-escalation refers to the strategy of discontinuing aspirin after a short period of dual antiplatelet therapy after PCI, leaving patients on monotherapy with a potent P2Y12 inhibitor—typically ticagrelor, as supported by available evidence.234 The rationale behind this approach is to maximise ischaemic protection during the initial months after PCI, when the thrombotic risk is highest, while simultaneously mitigating the bleeding risk, which remains relatively constant and is directly associated with DAPT duration.5 In a previous meta-analysis from our group, DAPT de-escalation was indeed associated with a significant reduction of bleeding events in patients with acute coronary syndrome compared with five alternative standard DAPT strategies, while not increasing the risk of ischaemic events, even rare ones, such as stent thrombosis.6

Cardiovascular research has struggled over the past decade to develop accurate scores to precisely estimate the trade-off between ischaemic and bleeding risks, even by means of artificial intelligence.789 However, most existing scores …