What antiplatelet regimen is recommended post thrombectomy and stent placement?

From the Guidelines

The recommended antiplatelet regimen following thrombectomy and stent placement typically consists of dual antiplatelet therapy (DAPT) with aspirin 75–100 mg and clopidogrel 75 mg daily for up to 6 months, as stated in the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Key Considerations

• The choice of P2Y12 inhibitor may be tailored to the individual patient's risk profile, with prasugrel or ticagrelor considered for patients at high thrombotic risk, as suggested by the 2024 ESC guidelines 1.
• For patients at high bleeding risk, a shorter DAPT duration of 1-3 months may be considered, as recommended by the 2024 ESC guidelines 1 and supported by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
• Medication adherence is essential, and patients should be counseled about the importance of not discontinuing therapy without consulting their physician, as premature discontinuation significantly increases the risk of stent thrombosis.

Antiplatelet Regimen Details

• Aspirin: 75–100 mg daily indefinitely
• P2Y12 inhibitor:
  • Clopidogrel: 75 mg daily for up to 6 months
  • Prasugrel or ticagrelor: may be considered for patients at high thrombotic risk, for the first month, and up to 3–6 months, as stated in the 2024 ESC guidelines 1

Special Considerations

• Patients with high ischemic risk and low bleeding risk may benefit from extended DAPT duration, as suggested by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
• Patients with high bleeding risk may require a shorter DAPT duration, as recommended by the 2024 ESC guidelines 1 and supported by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Initiate treatment with a single 60 mg oral loading dose (2). Continue at 10 mg once daily with or without food. Consider 5 mg once daily for patients <60 kg (2). Patients should also take aspirin (75 mg to 325 mg) daily (2). The antiplatelet regimen recommended post thrombectomy and stent placement is prasugrel (10 mg once daily) and aspirin (75 mg to 325 mg daily) 2.

• Key points:
  • Prasugrel: 10 mg once daily
  • Aspirin: 75 mg to 325 mg daily
  • Consider 5 mg once daily for patients <60 kg

From the Research

Antiplatelet Regimen Post Thrombectomy and Stent Placement

The antiplatelet regimen recommended post thrombectomy and stent placement is a crucial aspect of patient care. The following points highlight the key findings:

• Dual antiplatelet therapy with a thienopyridine (ticlopidine or clopidogrel) and aspirin is used to reduce the risk of late stent thrombosis and complications (myocardial infarction [MI] and death) after placement of a drug-eluting stent (DES) 3.
• The combination of clopidogrel (loading dose, 300-600 mg; maintenance dose, 75 mg/d) and low-dose aspirin (75-162 mg/d) for 12 months is the preferred regimen for the prevention of stent thrombosis and cardiac complications after DES placement 3.
• Triple antiplatelet therapy may be beneficial in certain high-risk patients, such as those with diabetes mellitus or ST-segment elevation MI undergoing DES placement 3.
• The use of prasugrel or ticagrelor as part of triple antithrombotic therapy among patients who underwent PCI and received warfarin was associated with significantly more bleeding compared to patients who received clopidogrel 4.
• In patients with acute ischemic stroke and tandem occlusions treated with carotid stent placement and mechanical thrombectomy, dual-antiplatelet therapy after hemorrhagic transformation had been ruled out on 24-hour CT was associated with functional independence and a lower risk of symptomatic intracranial hemorrhage 5.
• P2Y12 inhibitor monotherapy following DAPT discontinuation after PCI is associated with a significantly lower risk for MI and similar risk for major bleeding, suggesting a potentially relevant net clinical benefit vs aspirin monotherapy 6.
• Early (<24 hours) post-tPA antiplatelet use in select mechanical thrombectomy patients with luminal irregularities or underlying intracranial atherosclerotic disease may be safe and warrants further study 7.

Key Considerations

• The choice of antiplatelet regimen should be individualized based on patient risk factors and clinical presentation.
• The risk of bleeding should be carefully considered when selecting an antiplatelet regimen, particularly in patients receiving triple antithrombotic therapy.
• Further studies are needed to determine the optimal antiplatelet regimen for patients undergoing thrombectomy and stent placement.