Guideline Video

Guideline Resources

  • Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events/Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease
  • American College of Cardiology
  • June 30, 2026
  • Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events - Summary / Full-text
  • Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease - Summary / Full-text

Video Transcription

Just published June 30th, 2026, the American College of Cardiology’s two newest scientific statements. The first on Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events. This scientific statement provides a comprehensive, evidence-based overview of established and emerging indications for direct oral anticoagulants, or DOAC, therapy in primary and secondary prevention of thrombotic events. 

The second scientific statement is on Antiplatelet Therapy in the Management of Atherosclerotic Cardiovascular Disease. This statement provides a detailed overview of current evidence for the use of antiplatelets in the management of atherosclerotic cardiovascular disease, or ASCVD.

In today’s rapid update, we’ll just be going over a summary of consensus recommendations so for the full scientific statements, make sure to check it out on guidelinecentral.com

Let’s get started.

Starting with the scientific statement on Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events


For the section on DOACs for primary prevention of venous thromboembolism, or VTE, and stroke

  • Both DOACs and low molecular weight heparin, or LMWH, are appropriate for VTE prophylaxis post-total hip arthroplasty or total knee arthroplasty; DOACs are preferred when possible.
  • DOACs are appropriate for use in most patients with valvular heart disease and AF, except those with rheumatic mitral stenosis. In addition, they are inferior to vitamin K antagonists for patients with mechanical valves in preventing thromboembolic events.
  • Routine oral anticoagulation with a DOAC in patients who undergo transcatheter aortic valve implantation without another indication for anticoagulation is not currently recommended.
  • For many patients with chronic coronary disease and need for anticoagulation, DOAC monotherapy at regular dosing is a reasonable long-term strategy. In addition, rivaroxaban 2.5 mg twice daily can be considered in conjunction with low-dose aspirin therapy among high-risk patients with CAD or PAD to reduce risk of myocardial infarction, stroke, and cardiovascular death.

Next the section on Management and secondary prevention of VTE

  • DOACs are recommended as initial treatment for VTE in most patients except in select populations. Loading doses are different from maintenance dosing. Recent data suggest that an apixaban strategy may be superior to a rivaroxaban strategy due to lower bleeding and may be the agent of choice in this setting.
  • Extended treatment to prevent VTE should be considered for patients presenting with unprovoked VTE, those with recurrent episodes, and those with high risk profile of recurrence including multiple permanent risk factors. The treatment duration is typically indefinite, but bleeding risk should be reevaluated regularly. DOACs are superior to vitamin K antagonists for this indication in view of superior efficacy and lower risk of major bleeding compared to warfarin. Aspirin monotherapy has limited benefits for extended treatment of VTE.
  • Apixaban 2.5 mg twice daily, apixaban 5 mg twice daily, or rivaroxaban 10 mg daily can be used if extended anticoagulant treatment is indicated. Apixaban 2.5 mg twice daily has comparable efficacy to apixaban 5 mg twice daily and is associated with lower major bleeding. Dabigatran 150 mg twice daily can be prescribed for extended treatment; no dose reduction has been tested. Edoxaban has not been tested for extended treatment, but real-life studies suggest good tolerance and efficacy.

Then the section on Secondary prevention after acute stroke

  • For people with acute ischemic stroke and atrial fibrillation, or AF, DOAC initiation within 4 days reduces the risk of the composite outcome of recurrent ischemic stroke, symptomatic intracerebral hemorrhage, or ICH, or unclassified stroke within 30 days. This assumes exclusion of people with very severe stroke, severe space occupying hemorrhagic transformation, or endocarditis.

Moving on to the section on OAC in patients with ICH

  • Restarting anticoagulation in people with AF and ICH lowers ischemic events but raises risks of recurrent ICH and major bleeding, without a clear early mortality difference. For most patients, waiting 4–8 weeks is prudent. The net long-term benefit remains uncertain.
  • Left atrial appendage closure may be considered to reduce thromboembolic events in people with prior ICH and AF, who are considered unsuitable for long-term OAC therapy.

Next the section on Special considerations: DOACs in patients with CKD, liver disease, frailty, obesity, or prior bleeding

  • In CKD stage 4/5 and on dialysis with risk for thromboembolism, there are limited data to guide DOAC use. Apixaban can be considered for nonvalvular AF. Dabigatran should be avoided in patients on dialysis due to significant renal clearance.
  • In individuals with liver disease, the use of OAC is based on Child-Pugh class stages. All DOACs appear safe with Child-Pugh class A. For Child-Pugh class B, apixaban, dabigatran, and edoxaban can be used, whereas rivaroxaban should be avoided. For Child-Pugh class C, there is insufficient evidence to support DOAC use.
  • In frail individuals at risk for thromboembolism, apixaban is preferred because it shows consistent benefit across the range of frailty status and poses a lower risk of bleeding.
  • In elderly, frail patients in whom standard dose anticoagulation is typically not recommended despite thromboembolism risk, low-dose edoxaban can be considered.
  • In individuals with class 3 obesity and at risk for thromboembolism, rivaroxaban or apixaban are appropriate options.
  • In patients with a history of prior bleeding or elevated bleeding risk who require anticoagulation, apixaban or low-dose dabigatran are preferred.

On to the section on Cancer-associated thrombus (CAT)

  • In selected high-risk ambulatory patients with cancer, prophylactic anticoagulation with a DOAC or low molecular weight heparin, or LMWH, may be considered.
  • DOACs or LMWH can be used to treat CAT. DOACs are generally preferred over LMWH for the treatment of CAT because they are associated with a lower risk of VTE recurrence and a similar overall risk of major bleeding. Among DOACs, the evidence base is strongest for apixaban. Rivaroxaban and edoxaban are also acceptable options for CAT except in urologic, gastrointestinal, and gynecological cancers.
  • Long-term, sometimes indefinite anticoagulation should be considered in patients with active cancer after the initial 6 months of treatment. Apixaban 2.5 mg twice daily has similar efficacy to 5 mg twice daily with a lower bleeding risk. Other DOACs have not been tested with a reduced dose strategy for this indication. LMWH can also be considered.

Then the section on Anticoagulation after left atrial appendage closure or AF ablation

  • The optimal regimen for anticoagulation post-left atrial appendage closure remains uncertain because clinical decisions are driven by individual bleeding risk.
  • For individuals with low to intermediate risk for stroke, who maintain sinus rhythm after catheter ablation of AF, discontinuation of OAC 1-year post-AF ablation is a reasonable approach in the absence of other high-risk conditions warranting continued OAC use.

And last the section on Monitoring and follow-up

  • Patients receiving DOAC therapy should undergo periodic reassessment of bleeding risk, renal and hepatic function, concomitant medications, and adherence, with closer surveillance in those at higher risk for bleeding or drug accumulation.
  • Bleeding risk scores may be used to identify patients who warrant more frequent follow-up but should not be used in isolation to withhold anticoagulation; instead, clinicians should focus on mitigating modifiable bleeding risk factors and reinforcing patient education on signs and symptoms of bleeding.
  • At follow-up visits, clinicians should reassess adherence, affordability, drug–drug interactions, interval clinical events, and patient-specific factors to determine whether the selected DOAC and dose remain appropriate.

Next the scientific statement on Management of Atherosclerotic Cardiovascular Disease

Starting with the section on Ischemic vs bleeding risk in determining antiplatelet strategy

  • Shared decision-making for use of antiplatelet therapies is centered on understanding the risk of patient-specific future ischemic events compared with bleeding risk.
  • Using risk calculators such as dual antiplatelet therapy, or DAPT, PRECISE-DAPT, and ARC-HBR can be helpful, but decision-making requires global assessment of future ischemic risk balanced against bleeding risk.

Next the section on Aspirin for primary prevention of ASCVD events

  • Aspirin may be effective in primary prevention of cardiovascular events, but is associated with increased risk of major bleeding. The current lack of benefit with aspirin for primary prevention may be due to the application of other effective preventive strategies like statins.
  • Low-dose aspirin might be considered for primary prevention of ASCVD events among adults aged 40-70 y who have a higher cardiovascular risk without an increased bleeding risk.
  • Routine use of aspirin for prevention in those over age 70 y should be avoided.
  • Available ASCVD calculators may help identify patients at high ischemic risk. If these patients are at low bleeding risk, aspirin may be considered for primary prevention. Use of aspirin in those with HBR is associated with net harm regardless of CAC score or ASCVD risk.

On to the section on Antiplatelet therapy postrevascularization

  • In patients with ACS undergoing percutaneous coronary intervention, or PCI, prasugrel or ticagrelor are preferred as the P2Y12 inhibitor of choice, with some data favoring prasugrel. Clopidogrel may be preferentially considered in patients >75 y of age due to increased risk of major bleeding with prasugrel or ticagrelor.
  • The default DAPT duration post-PCI is 6 mo for CCD and 12 mo for ACS. Aspirin should be maintained in the peri-PCI period. Shortened DAPT followed by P2Y12 inhibitor monotherapy can reduce bleeding without increasing ischemic events. Shortened DAPT followed by P2Y12 inhibitor monotherapy can reduce bleeding without increasing ischemic events. This approach is mainly applicable to ticagrelor or prasugrel, not clopidogrel or aspirin unless the patient is HBR. Caution is also advised in patients with higher ischemic risk, such as those presenting with STEMI.
  • Guided or unguided deescalation from either ticagrelor or prasugrel to clopidogrel 1 mo after ACS treated with PCI may be an option in selected patients to lower bleeding risk.
  • DAPT reduces the risk of vein graft failure after CABG but has little effect on clinical outcomes except for increasing the risk of bleeding.

Moving on to the section on Long-term antiplatelet therapy after ACS or MI

  • Beyond 1 y after ACS, emerging data suggest that clopidogrel monotherapy may offer greater ischemic protection with similar or lower bleeding risk compared with aspirin monotherapy for secondary CAD prevention.
  • Intensified strategies, including prolonged DAPT, P2Y12 inhibitor monotherapy, or anticoagulant-based regimens, may be appropriate in selected high-risk patients, but ischemic benefit should be consistently weighed against risk of increased bleeding. Individualized assessment of ischemic and bleeding risk remains central to long-term antithrombotic decision-making.
  • Rivaroxaban 2.5 mg twice daily with aspirin 81 mg daily can be considered for long-term use in select high-risk patients with stable CAD or PAD who do not have a history of previous major bleeding or cerebrovascular accident.

Next the section on Special considerations: PAD, stroke, TIA, valve disease, and patients requiring anticoagulation

  • Antiplatelet therapy has an important role in the acute and chronic management of PAD and cerebrovascular disease, similar to CAD. However, compared with CAD, shorter durations of DAPT are typically recommended postrevascularization.
  • Adding rivaroxaban 2.5 mg twice daily to low-dose aspirin is a reasonable long-term strategy in patients with PAD to reduce major adverse cardiac events and major adverse limb events, particularly among high-risk patients who have acceptable bleeding risk.
  • In patients with minor ischemic stroke or high-risk TIA, early initiation of DAPT with aspirin plus clopidogrel within 12–24 h, continued for 21 d, reduces early recurrent stroke compared with aspirin alone, after which therapy is deescalated to antiplatelet monotherapy to limit bleeding risk. The use of DAPT among patients who receive thrombolysis or have more severe strokes is unclear.
  • Triple therapy among patients needing OAC and antiplatelet therapy should be avoided. Aspirin can typically be discontinued within 1 mo of PCI; clopidogrel and DOACs are the favored agents for antithrombotic therapy in these patients. Long-term management can include DOACs as monotherapy.
  • Patients receiving bioprosthetic aortic or mitral valves can be managed with single antiplatelet therapy long term.

Next the section on Perioperative management of antiplatelet therapy

  • The 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery recommends strategies of deferring elective surgery ≥6 mo after PCI for CCS and 12 mo after PCI for ACS. After this time, P2Y12 inhibitors can be stopped but low-dose aspirin should be continued. In the current era, shorter DAPT durations can be considered in carefully selected patients.
  • The recommended timing of stopping P2Y12 inhibitors before surgery is based on the half-life of these drugs. Clopidogrel and ticagrelor are stopped 5 d before surgery and prasugrel 7 d before surgery.
  • Urgent noncardiac surgery may require cessation of P2Y12 agents and bridging with a shorter-acting intravenous antiplatelet agent, or the use of platelet transfusion for more urgent cases.

Then the section on Monitoring of patients on antiplatelet therapy

  • Considerable variability exists in patients’ response to antiplatelet therapy, particularly with clopidogrel. Although routine platelet function testing and genotyping are not universally recommended, they may have a role in guiding deescalation of P2Y12 inhibitor therapy.
  • Routine PPI therapy is recommended for patients at high risk of bleeding or for those requiring concomitant anticoagulant use. Concerns that concomitant omeprazole reduces clopidogrel efficacy have not been proved clinically.

And last the section on Adherence to antiplatelet therapy

  • Medication adherence to DAPT and antiplatelet therapy remains a major challenge after MI, with nonadherence, particularly early post-PCI, associated with higher risk of stent thrombosis and major adverse cardiac events.
  • Factors contributing to poor adherence include older age, polypharmacy, socioeconomic barriers, high drug costs, and medication-related adverse effects such as bleeding or dyspnea.
  • Strategies to improve adherence may include early postdischarge follow-up, culturally sensitive patient education, addressing social drivers of health such as financial burden, close monitoring for bleeding and other adverse effects, dose adjustment or deescalation of therapy when appropriate, and potentially the use of fixed-dose polypill combinations. Multifaceted and multilevel approaches are essential.

And there you have it. Make sure to check out the full scientific statements from the American College of Cardiology and other related clinical decision support tools at guidelinecentral.com.

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