New ACC statement reshapes antiplatelet therapy across ASCVD

Clinical takeaway: Reassess antiplatelet regimens through the lens of bleeding risk. For many patients, shorter DAPT courses and transition to P2Y12 inhibitor monotherapy—particularly clopidogrel in the long term—may provide a more favorable balance of efficacy and safety than traditional aspirin-based approaches.

A new 2026 ACC Scientific Statement provides a comprehensive review of antiplatelet therapy across the spectrum of atherosclerotic cardiovascular disease (ASCVD), emphasizing individualized treatment decisions that balance ischemic protection against bleeding risk.

Among the most notable shifts is growing support for clopidogrel monotherapy beyond 1 year after ACS or PCI. Recent trials suggest clopidogrel may reduce ischemic events while producing similar or even less bleeding than aspirin, raising questions about aspirin’s long-standing role as the default chronic therapy.

For patients undergoing PCI, the statement affirms prasugrel or ticagrelor as preferred P2Y12 inhibitors in ACS, with clopidogrel remaining an option for older adults, those at high bleeding risk, or when cost or tolerability is a concern. Standard DAPT duration remains 12 months after ACS and 6 months after PCI for chronic coronary disease, but shorter courses followed by ticagrelor or prasugrel monotherapy can be considered in carefully selected patients.

In primary prevention, the authors reinforce that aspirin should be used sparingly. Low-dose aspirin may be considered only in adults aged 40–70 years with elevated cardiovascular risk and low bleeding risk, while routine use in adults older than 70 years should be avoided.

The statement also highlights expanded evidence for rivaroxaban 2.5 mg twice daily plus aspirin in selected patients with stable CAD or PAD who have high ischemic risk and acceptable bleeding risk.

“Achieving an appropriate balance between the risks of ischemia and bleeding poses a perpetual challenge, requiring recommendations tailored to the individual,” the writing committee notes.

The document also devotes significant attention to medication adherence, identifying older age, polypharmacy, socioeconomic barriers, drug costs, bleeding, and ticagrelor-related dyspnea as major contributors to treatment discontinuation. Recommended solutions include early post-discharge follow-up, culturally sensitive education, addressing financial barriers, monitoring adverse effects, therapy de-escalation when appropriate, and potential use of fixed-dose polypill combinations.

What’s changed

• Clopidogrel monotherapy is emerging as a preferred long-term option after ACS or PCI, with newer data suggesting greater ischemic protection and similar or lower bleeding risk than aspirin alone.
• Shortened DAPT (1–3 months) followed by P2Y12 inhibitor monotherapy is increasingly supported for selected patients after PCI to reduce bleeding risk without increasing ischemic events.
• Prasugrel and ticagrelor remain the preferred P2Y12 inhibitors after ACS, although some data favor prasugrel in PCI-treated patients.
• Routine aspirin use for primary prevention continues to narrow and should generally be avoided in adults >70 years or those at elevated bleeding risk.
• Triple therapy with anticoagulation plus dual antiplatelet therapy should be minimized, with aspirin typically discontinued within 1 month after PCI.

Source: Kumbhani DJ, et al. (2026 June 30) J Am Coll Cardiol. Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease: 2026 ACC Scientific Statement: A Report of the American College of Cardiology