DAPT complications — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 68-year-old man had PCI with a drug-eluting stent for NSTEMI 5 weeks ago and takes aspirin and ticagrelor. He presents with melaena and a haemoglobin of 7.9 g/dL; he needs transfusion, and endoscopy controls a bleeding duodenal ulcer. He has no other ARC-HBR criteria.^[1][2]

1. Why does ESC 2023 treat this bleed as more than a local problem? (2)^[1]
2. Using ACC/AHA 2025 Table 22, is he now at high bleeding risk? Explain. (2)^[2]
3. Give one ESC 2023 row and one ACC/AHA 2025 row for antiplatelet therapy in patients at high bleeding risk 1 month after PCI, with class and level. (2)^[1][2]
4. State the ESC 2023 and ACC/AHA 2025 PPI rows, and the PPI–clopidogrel caution. (2)^[1][2]
5. How do ESC 2023 and ACC/AHA 2025 differ on red cell transfusion in ACS? (2)^[1][2]

Model answers — SAQ 1

1. ESC 2023: bleeding is associated with a poor prognosis in ACS; less severe bleeding may increase the risk of death through indirect mechanisms, and transfusion may increase systemic inflammation (1 mark).^[1] Bleeding is a major driver of unplanned DAPT discontinuation and of interruption of other medication such as statins and beta-blockers (1 mark).^[1]
2. Yes: spontaneous bleeding requiring hospitalisation or transfusion in the past 6 months is a major criterion, and haemoglobin under 11 g/dL is a second major criterion (1 mark).^[2] ACC/AHA 2025 says at least 1 major or 2 minor criteria helps to identify those at increased risk of bleeding (1 mark).^[2]
3. ESC 2023: in HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered (Class IIb, Level B) (1 mark).^[1] ACC/AHA 2025: in patients with ACS undergoing PCI who are at high bleeding risk, transition to SAPT (aspirin or P2Y12 inhibitor) after 1 month may be reasonable to reduce bleeding risk (COR 2b, LOE B-R) (1 mark).^[2]
4. ESC 2023: a PPI with DAPT is recommended in patients at high risk of gastrointestinal bleeding (Class I, Level A); ACC/AHA 2025: a PPI is recommended with DAPT, oral anticoagulants or both in patients at high risk of gastrointestinal bleeding (COR 1, LOE A) (1 mark).^[1][2] ESC 2023: PPIs that inhibit CYP2C19, particularly omeprazole and esomeprazole, may reduce the pharmacodynamic response to clopidogrel, without strong evidence of more ischaemic events; no interaction with aspirin, prasugrel or ticagrelor has been observed (1 mark).^[1]
5. ESC 2023: after REALITY, whose 1-year follow-up gave conclusions contradicting the 30-day result, no formal recommendation on liberal versus restrictive transfusion in ACS can be made at present (1 mark).^[1] ACC/AHA 2025: in ACS with acute or chronic anaemia, transfusion to a haemoglobin of 10 g/dL or more may be reasonable to reduce cardiovascular events (COR 2b, LOE B-R); the row cites MINT, which, as ACC/AHA 2025 reports it, randomly assigned 3,504 patients with STEMI or NSTEMI and haemoglobin under 10 g/dL to restrictive or liberal transfusion, with 30-day death or recurrent MI as the primary outcome (1 mark).^[2]

SAQ 2 (10 marks)

Practice scenario. A 74-year-old woman with paroxysmal atrial fibrillation (CHA2DS2-VASc score 4) on a DOAC has an NSTEMI treated with an uncomplicated PCI; her thrombotic risk is judged low. Four months later she is listed for an elective laparoscopic cholecystectomy.^[5][1][7]

1. State the ESC 2023 ACS default regimen for her, with class and level. (2)^[1]
2. What does the ESC 2024 AF row, newer than ESC 2023 ACS, add for her, with class and level? (2)^[5][1]
3. Which P2Y12 inhibitors does ESC 2023 not recommend as part of triple therapy, and why does ACC/AHA 2025 favour clopidogrel? (2)^[1][2]
4. When should her elective cholecystectomy be done under ESC 2022? (2)^[7]
5. If antiplatelet therapy is interrupted for an operation, when does ESC 2022 recommend restarting it, and how is the antiplatelet plan agreed? (2)^[7]

Model answers — SAQ 2

1. ESC 2023, for AF with a CHA2DS2-VASc score of 1 or more in men and 2 or more in women: after up to 1 week of triple antithrombotic therapy following the ACS event, dual antithrombotic therapy with a NOAC at the stroke-prevention dose and a single oral antiplatelet agent (preferably clopidogrel) for up to 12 months (1 mark).^[1] This default is recommended (Class I, Level A) (1 mark).^[1]
2. ESC 2024 AF: early cessation (1 week or less) of aspirin and continuation of an oral anticoagulant (preferably a DOAC) with a P2Y12 inhibitor (preferably clopidogrel) for up to 12 months is recommended in AF patients with ACS undergoing an uncomplicated PCI, to avoid major bleeding, if the risk of thrombosis is low or bleeding risk is high (1 mark).^[5] Class I, Level A; antiplatelet therapy beyond 12 months is not recommended in stable patients with chronic coronary or vascular disease treated with oral anticoagulation, due to lack of efficacy and to avoid major bleeding (Class III, Level B) (1 mark).^[5]
3. ESC 2023: the use of ticagrelor or prasugrel as part of triple antithrombotic therapy is not recommended (Class III, Level C) (1 mark).^[1] ACC/AHA 2025: trials of prasugrel and ticagrelor excluded patients requiring long-term anticoagulation, so clopidogrel is generally favoured in this setting for most patients (1 mark).^[2]
4. ESC 2022 recommends delaying elective non-cardiac surgery until 6 months after elective PCI and 12 months after an ACS (Class I, Level A) (1 mark).^[7] On combination therapy, elective surgery should be postponed until antiplatelet therapy can be safely discontinued (6 months after elective PCI or 12 months after ACS), so her elective operation waits until 12 months after the NSTEMI (1 mark).^[7]
5. Restarting as soon as possible (within 48 h) after surgery, according to interdisciplinary risk assessment, is recommended (ESC 2022, Class I, Level C) (1 mark).^[7] After a recent PCI, management of antiplatelet therapy should be discussed between the surgeon, anaesthesiologist and cardiologist (ESC 2022, Class I, Level C) (1 mark).^[7]