The American College of Cardiology (ACC) recently released two guidance statements regarding the prevention of thrombotic events and managing atherosclerotic cardiovascular disease (ASCVD). Both statements were published on June 30, 2026, and we have consensus recommendations from each below. 

The ACC statement on preventing thrombotic events, Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events reviews established indications for direct oral anticoagulants (DOACs) in primary and secondary prevention of thrombotic events. The statement also discusses dosing strategies, management of anticoagulant-related bleeding, cost-related barriers to care, and more. 

The ACC statement on ASCVD, Antiplatelet Therapy in the Management of Astherosclerotic Cardiovascular Disease, features an overview of the latest evidence regarding the use of antiplatelets in managing ASCVD. Additionally, the statement addresses topics including long-term monitoring, adherence, a clinical practice guideline comparison, and a summary of key clinical trials. 

Consult the full-text versions of the prevention of thrombotic events statement and ASCVD statement for the complete listing of consensus statement recommendations along with their provided rationale.

Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events - Key Recommendations

DOACs for Primary Prevention of Venous Thromboembolism and Stroke: 

  • Both DOACs and low molecular weight heparin are appropriate for venous thromboembolism 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 atrial fibrillation, 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 anticoagulant 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 coronary artery disease or peripheral artery disease to reduce risk of myocardial infarction, stroke, and cardiovascular death.

Management and Secondary Prevention of Venous Thromboembolism:

  • DOACs are recommended as initial treatment for venous thromboembolism in most patients, except in select populations (e.g., mechanical valves, severe renal dysfunction). 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 (beyond six months) to prevent venous thromboembolism should be considered for patients presenting with unprovoked venous thromboembolism, those with recurrent episodes, and for those with a 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 venous thromboembolism.
  • 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 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.

Secondary Prevention After Acute Stroke:

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

DOACs in Patients with Chronic Kidney Disease / End-Stage Kidney Disease:

  • In chronic kidney disease stage 4/5 and on dialysis with risk for thromboembolism, there are limited data to guide DOAC use. Apixaban can be considered for nonvalvular atrial fibrillation (with label-concordant dosing). Dabigatran should be avoided in dialysis patients due to significant renal clearance.

DOACs in Patients with Liver Disease:

  • In individuals with liver disease, the use of oral anticoagulants 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.

DOACs in Patients with Prior Bleeding or Elevated Bleeding Risk:

  • In patients with a history of prior bleeding or elevated bleeding risk who require anticoagulation, apixaban or low-dose dabigatran (110 mg twice daily) are preferred.

Cancer-Associated Thrombus (CAT):

  • In selected high-risk ambulatory patients with cancer, prophylactic anticoagulation with a DOAC (apixaban or rivaroxaban) or low molecular weight heparin (dalteparin or enoxaparin) may be considered.
  • DOACs or low molecular weight heparin can be used to treat CAT. DOACs are generally preferred over low molecular weight heparin for the treatment of CAT because they are associated with a lower risk of venous thromboembolism 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. Low molecular weight heparin can also be considered.
Antiplatelet Therapy in the Management of Astherosclerotic Cardiovascular Disease - Key Recommendations

Ischemic versus 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 DAPT, PRECISE-DAPT, and ARC-HBR can be helpful, but decision-making requires global assessment of future ischemic risk balanced against bleeding risk.

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 who have a higher cardiovascular risk without an increased bleeding risk.
  • Routine use of aspirin for prevention in those over age 70 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 high bleeding risk is associated with net harm regardless of coronary artery calcium score or ASCVD risk.

Long-Term Antiplatelet Therapy After Acute Coronary Syndrome or Myocardial Infarction:

  • Beyond one year after acute coronary syndrome, emerging data suggest that clopidogrel monotherapy may offer greater ischemic protection with similar or lower bleeding risk compared with aspirin monotherapy for secondary coronary artery disease prevention.
  • Intensified strategies, including prolonged dual antiplatelet therapy, 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 coronary artery disease or peripheral artery disease who do not have a history of previous major bleeding or cerebrovascular accident.

Special Considerations: Peripheral Artery Disease, Stroke, Transient Ischemic Attack, Valve Disease, and Patients Requiring Anticoagulation: 

  • Antiplatelet therapy has an important role in the acute and chronic management of peripheral artery disease and cerebrovascular disease, similar to coronary artery disease. However, compared with coronary artery disease, shorter durations of dual antiplatelet therapy (one to six months) are typically recommended postrevascularization.
  • Adding rivaroxaban 2.5 mg twice daily to low-dose aspirin is a reasonable long-term strategy in patients with peripheral artery disease 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 (NIHSS score of ≤3) or high-risk transient ischemic attack (ABCD2 score of ≥4), early initiation of dual antiplatelet therapy with aspirin plus clopidogrel within 12–24 hours, continued for 21 days, reduces early recurrent stroke compared with aspirin alone, after which therapy is deescalated to antiplatelet monotherapy to limit bleeding risk. The use of dual antiplatelet therapy among patients who receive thrombolysis or have more severe strokes (NIHSS score of >5) is unclear.
  • Triple therapy among patients needing oral anticoagulant and antiplatelet therapy should be avoided. Aspirin can typically be discontinued within one month of percutaneous coronary intervention; clopidogrel and DOACs are the favored agents for antithrombotic therapy in these patients. Long-term management (beyond one year) can include DOACs as monotherapy.
  • Patients receiving bioprosthetic aortic or mitral valves can be managed with single antiplatelet therapy (typically low-dose aspirin) long term.

Adherence to Antiplatelet Therapy:

  • Medication adherence to dual antiplatelet therapy and antiplatelet therapy remains a major challenge after myocardial infarction, with nonadherence, particularly early post-percutaneous coronary intervention, associated with higher risk of stent thrombosis and major adverse cardiac event.
  • 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 (e.g., patient, family, healthcare system) approaches are essential.

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