Gaining insights on optimal duration of dual antiplatelet therapy in patients with acute coronary syndrome: Cardiologist consensus from India (GOLD-DAPT)

Abstract

The optimal duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) continues to evolve, but current recommendations derived largely from Western data may not reflect the clinical profile of Indian patients, underscoring the need for region-specific guidance. To develop consensus-based, India-specific recommendations on DAPT duration in ACS by integrating global evidence with real-world clinical considerations. A modified Delphi process was conducted among experienced interventional cardiologists across India. Participants reviewed evidence summaries and anonymously rated ten statements on prolonged, shortened, and risk-stratified DAPT strategies. Consensus was defined as ≥75% agreement. All 34 cardiologists completed the survey (100% response). Consensus (≥≥70%) was achieved for all statements. Strong agreement supported prolonged DAPT in high-thrombotic-risk ACS (97.1%) and balancing ischemic and bleeding risks (94.1%). Agreement with the ESC 6-month DAPT recommendation for stable DES percutaneous coronary intervention (PCI) was lower (61.8%), reflecting preference for extended therapy in Indian practice. While short DAPT reduced bleeding (85.3%), most experts acknowledged higher MI risk in ACS, consistent with SMART-DATE and STOPDAPT-2 ACS (79.4%). Prolonged DAPT (≥≥12 months) in complex PCI received strong support (97%), with universal agreement that it reduces MACE and cardiothrombotic events (100%). Key factors favoring extended therapy included smoking and prior MI/stent thrombosis (97% each), as well as procedural complexity. Routine PPI cotherapy was endorsed by 79.4%. The GOLD-DAPT consensus offers practical, risk-adapted recommendations for Indian ACS patients, supporting individualized rather than fixed-duration DAPT and emphasizing the need for India-specific prospective data to guide future national policy.