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Seyed Amir Raoufi: A Shift from ‘Triple or Dual Therapy’ to ‘De-escalation and Monotherapy’
Seyed Amir Raoufi/LinkedIn
May 3, 2026, 07:05

Seyed Amir Raoufi: A Shift from ‘Triple or Dual Therapy’ to ‘De-escalation and Monotherapy’

Seyed Amir Raoufi, Interventional Cardiologist, shared a post on LinkedIn:

“​The current guidelines emphasize a shift from ‘Triple or Dual Therapy’ to ‘De-escalation and Monotherapy’ in stable patients to minimize bleeding complications while maintaining ischemic protection.

​1. Coronary Artery Disease (CAD) without Stenting

​For patients with documented coronary plaques (via Angio or CCTA) not requiring revascularization:

  • ​Standard Care: SAPT (Single Antiplatelet Therapy) with Aspirin (75-100 mg).
  • ​2026 Shift: In patients with high GI bleeding risk, Clopidogrel (75 mg) monotherapy is now preferred over Aspirin for long-term maintenance (as supported by the HOST-EXAM trial data).

​2. Carotid Artery Disease

  • ​Asymptomatic Stenosis low then 50%: Aspirin 100 mg is generally sufficient.
  • ​Asymptomatic Stenosis high then 50%: SAPT (Aspirin or Clopidogrel) is a Class I recommendation.
  • ​Clinical Pearl: Aggressive LDL-C lowering to low then 55 mg/dL (1.4 mmol/L) is often more prognostic than the choice of antiplatelet agent in carotid disease.

​3. Peripheral Artery Disease (PAD) and Aortic Plaques

  • Stable PAD (Claudicants): Clopidogrel has shown a slight edge over Aspirin in preventing limb-related events.
  • ​High-Risk PAD: For those at high risk of limb loss or major cardiovascular events, the ‘Vascular Dose’ combination is preferred: Aspirin 100 mg plus Rivaroxaban
  • 2.5 mg BID (COMPASS trial protocol).
  • ​Aortic Plaques: SAPT is recommended only for Complex Plaques (high then 4mm or mobile). Simple aortic debris usually requires lifestyle/statin therapy unless

CAD/Stroke is co-present.

​4. Bioprosthetic Valves (SAVR and TAVI)

  • ​Surgical Valves (SAVR): Aspirin (75-100 mg) is the gold standard for life (post an initial 3-6 month window of OAC or SAPT).
  • ​TAVI/TAVR: Consistent with the POPular-TAVI trial, Aspirin monotherapy is the Class I recommendation. Adding Clopidogrel increases bleeding risk without reducing valve thrombosis.

​5. Post-Stroke Secondary Prevention

  • ​Chronic Phase: SAPT (ideally Clopidogrel or Aspirin).
  • ​Acute Phase (Minor Stroke/TIA): Short-term DAPT (Aspirin plus Clopidogrel) for 21 to 90 days followed by a mandatory switch to SAPT.

​6. Chronic Phase Post-PCI (high then 1 Year)

  • ​For the majority of patients, DAPT should be discontinued at 12 months.
  • ​2026 Recommendation: Transition to Clopidogrel monotherapy is increasingly favored over Aspirin for long-term CAD management due to a better safety-efficacy profile.

​7. Patients Requiring Oral Anticoagulation (OAC)

​This is a critical area of practice for patients with Atrial Fibrillation (AF) and stable vascular disease.

  • ​The 2026 Golden Rule: In patients with Stable Vascular Disease (no PCI/ACS within the last 12 months) who require OAC (NOACs or Warfarin), antiplatelet therapy should be discontinued.
  • ​Rationale: Adding Aspirin to a NOAC in stable patients doubles the bleeding risk without significantly reducing ischemic events (AFIRE trial).
  • ​Exception: Antiplatelets are only combined with OAC during the ‘vulnerable window’ (usually 1–6 months) following an Acute Coronary Syndrome or Stenting”

Seyed Amir Raoufi

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Aortic Plaques Bioprosthetic Valves CAD Chronic Phase Post-PCI Coronary Artery Disease De-escalation and Monotherapy Health Hematology Hemostasis Hemostasis News Hemostasis Today Medicine OAC Oral Anticoagulation PAD Peripheral Artery Disease Post-Stroke Secondary Prevention SAVR Seyed Amir Raoufi TAVI Triple or Dual Therapy
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