The pharmacology and clinical evidence for the use of dual versus single antiplatelet therapy

INTRODUCTION: In patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI), long-term dual antiplatelet therapy (DAPT) is the current standard of care. However, recent evidence suggests that shortening DAPT duration in favor of single antiplatelet therapy (SAPT) can optimize the overall clinical benefit, as it can prevent bleeding without significant tradeoff in ischemic events. AREAS COVERED: In this narrative review, we synthesize current evidence from PubMed and SCOPUS on SAPT vs DAPT regimens in CAD patients undergoing PCI, including pharmacodynamic and clinical outcomes data, and we propose an algorithm for appropriate antiplatelet regimen selection depending on the ischemic and bleeding risk profile of the individual patient. EXPERT OPINION: The landscape of antiplatelet treatment regimens has significantly evolved over time, with the current trend being toward a tailored approach based on risk profile, aiming to reduce the risk of bleeding while maintaining ischemic protection. The accurate evaluation of each patient's ischemic and bleeding risk profile is of utmost importance. Dedicated tools have been developed to optimize patient risk profiling and help guide the selection of the antiplatelet regimen. Based on risk estimation, several strategies can be used to reduce the overall risk, including the selection and duration of the antiplatelet regimen.