Dual antiplatelet therapy escalation and de-escalation

Dual antiplatelet therapy (DAPT) remains a key element of secondary prevention after percutaneous coronary intervention. However, its optimal duration and intensity continue to pose challenges due to the trade-off between ischaemic protection and bleeding risk. Over the past decade, evidence has progressively emerged for strategies of DAPT modulation, with particular emphasis on de-escalation approaches. Randomized trials have consistently shown that reducing antiplatelet intensity, whether by lowering the dose, discontinuing one drug, or switching to a less potent agent, can mitigate bleeding events without jeopardizing ischaemic outcomes in selected patients. In contrast, escalation strategies have received less widespread adoption, reflecting more limited evidence, weaker guideline support, and the fact that most contemporary patients are at greater risk of bleeding than thrombosis. This review aims to summarize the evidence supporting DAPT modulation strategies, to critically appraise available trials, and to highlight ongoing studies in the field.