A new scientific statement from the American College of Cardiology (ACC) has pulled together recommendations on antiplatelet medication use across primary and secondary prevention settings.

These evidence-based consensus recommendations, published in the Journal of the American College of Cardiology, provide the big picture view of antiplatelet medication management in prevention of atherosclerotic cardiovascular disease (ASCVD).

“There are a number of guidelines on this topic but each addresses a specific disease condition,” said writing group chair Dharam J. Kumbhani, MD, SM, of UT Southwestern Medical Center in Dallas. “This flips the script a little bit and puts it all together for all these various conditions.”

That’s helpful as patients transition across acute and chronic phases of disease and have overlapping conditions, Kumbhani noted.

“It’s not meant to be prescriptive in the same way that a guideline document is,” he said in an interview. Nor does the statement override existing specific condition-based guidelines, he told Medscape Medical News. Rather, the group provided a comparison across the multiple guidelines available for managing patients with antiplatelet agents across the spectrum of ASCVD: 

• 2025 ACC/American Heart Association (AHA) guideline for management acute coronary syndromes (ACS)
• 2023 AHA/ACC guideline on chronic coronary disease
• 2023 European Society of Cardiology (ESC) ACS guidelines
• 2024 ESC guidelines on chronic coronary syndromes

The statement points to harmony between American and European guidelines on 12 months of dual antiplatelet therapy (DAPT) as the default strategy after an ACS, on aspirin for medically treated patients with chronic coronary syndromes or remote coronary revascularization, and on DAPT duration after percutaneous coronary intervention (PCI).

But “important differences exist,” the statement adds. “For example, the 2023 ESC ACS guidelines recommend prasugrel in preference to ticagrelor for patients with ACS who proceed to PCI (ESC Class IIa). No analogous recommendation exists in the 2025 ACC/AHA ACS guidelines.”

The statement builds on those guidelines with newer evidence on scenarios of when to consider a shorter duration and with what agent, with the bulk of the evidence for ticagrelor monotherapy after shortened DAPT and for some coronary disease patients to transition to clopidogrel monotherapy rather than aspirin, Kumbhani said.

Perhaps most useful, commented Behnood Bikdeli, MD, of Brigham and Women’s Hospital in Boston, is the central illustration in the document, which outlines algorithms for short- and long-term management across conditions ranging from higher to lower bleeding risk.

“Practically speaking, it encapsulates a lot of helpful information for the clinician…kind of a one-stop-shop summary type of display,” he said.

While there were some “minor changes” due to updated guidance from what was available for the published guidelines, “the most notable is there is stronger evidence both for ACS and PCI than before that a short-term period of management with DAPT is now being considered very safe,” Bikdeli said. “And in many patients, assuming there were no major procedural complications, stent-related complications, or unique patient-related factors, patients should often be de-escalated from DAPT to single antiplatelet therapy within weeks to months rather than years.”

The document also compares low-dose rivaroxaban against DAPT for peripheral artery disease, discusses aspirin primary prevention for high coronary calcium and other high-risk patients, and delves into antiplatelet therapy for cerebrovascular and valvular disease and use alongside oral anticoagulants.

“This piece is moving us forward in many ways,” Bikdeli said. “There are a few open questions still remaining, and part of that is still because of lack of high-quality source information.” He cited antiplatelet decision guidance, especially for P2Y12 inhibitors, as an example where it’s clear that there are biologic differences but trials haven’t proven benefit to strategies based on them.

“This document gives some entering guidance for clinicians to be able to think more clearly of how to use antiplatelet therapy for atherosclerotic cardiovascular disease. But also I’m hopeful maybe by the next 5 years is the right time, we will have more information to hopefully push things toward more effective platelet inhibition.”

Kumbhani reported no relevant conflicts of interest. Coauthors disclosed relationships with a number of companies with an interest in antiplatelet medication use.

Bikdeli reported being supported by a Career Development Award from the American Heart Association and VIVA Physicians. He also disclosed having relationships with the APS Foundation of America, the Vasculearn Network, and the National Heart, Lung, and Blood Institute. He reported receiving compensation for editing roles with the NEJM Clinician, Thrombosis Research, Journal of the American College of Cardiology, and Thrombosis and Haemostasis.

Crystal Phend is an award-winning medical journalist with decades of experience reporting on clinical research and healthcare developments across specialties. When not walking the halls at a medical conference, she can be found at a keyboard in upstate New York.