What are the guidelines for cardiac stent placement and management, including choice of stent and antiplatelet therapy?

From the Guidelines

Cardiac stent placement requires careful consideration of stent type and antiplatelet therapy based on patient-specific factors, with drug-eluting stents (DES) generally preferred over bare-metal stents (BMS) due to lower restenosis rates. Following stent placement, dual antiplatelet therapy (DAPT) consisting of aspirin (81mg daily indefinitely) plus a P2Y12 inhibitor is essential. For DES, P2Y12 inhibitors (clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) should be continued for at least 6-12 months, while BMS requires at least 1 month, as supported by the 2021 guideline update 1. High-risk patients with acute coronary syndrome may benefit from more potent agents like ticagrelor or prasugrel and longer DAPT duration. Some key points to consider include:

• The choice of stent and antiplatelet regimen ultimately depends on the patient's coronary anatomy, comorbidities, bleeding risk, and likelihood of future procedures requiring DAPT interruption.
• Pre-procedural loading doses (aspirin 325mg, clopidogrel 600mg, ticagrelor 180mg, or prasugrel 60mg) should be administered before PCI when possible.
• Regular monitoring for bleeding complications and medication adherence is crucial, as premature discontinuation significantly increases stent thrombosis risk, with a study showing an HR of 161 for these events 1.
• For patients requiring anticoagulation, careful balancing of bleeding and thrombotic risks is necessary, often using triple therapy (DAPT plus anticoagulant) for a limited period followed by dual therapy, with a suggested approach of triple therapy for 1-3 months, followed by dual therapy with OAC plus single antiplatelet until 12 months, as recommended in the 2018 Chest guideline 1. The most recent and highest quality study, from 2021, recommends prasugrel as the first line agent in ACS, unless the patient is on anticoagulant therapy, in which case clopidogrel is recommended 1.

From the FDA Drug Label

The optimal duration of thienopyridine therapy is unknown In patients who are managed with PCI and stent placement, premature discontinuation of any antiplatelet medication, including thienopyridines, conveys an increased risk of stent thrombosis, myocardial infarction, and death.

Initiate prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily. Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The guidelines for cardiac stent placement and management include:

• Antiplatelet therapy: Prasugrel should be initiated with a 60 mg loading dose and continued at 10 mg once daily, along with aspirin (75 mg to 325 mg) daily 2.
• Choice of stent: The drug label does not provide information on the choice of stent.
• Duration of therapy: The optimal duration of thienopyridine therapy is unknown, but premature discontinuation conveys an increased risk of stent thrombosis, myocardial infarction, and death 2.
• Dosing in special populations: Consider lowering the maintenance dose to 5 mg in patients <60 kg due to increased exposure to the active metabolite and risk of bleeding 2.
• Management of bleeding: Bleeding events can be managed with transfusion of blood products, including packed red blood cells and platelets; however, platelet transfusions within 6 hours of the loading dose or 4 hours of the maintenance dose may be less effective 2.

From the Research

Guidelines for Cardiac Stent Placement and Management

• The choice of stent and antiplatelet therapy is crucial in cardiac stent placement and management 3, 4, 5, 6, 7.
• Drug-eluting stents (DES) are preferred over bare-metal stents (BMS) due to their antirestenotic efficacy, despite the relative risk of stent thrombosis and adverse cardiovascular events being unclear 3, 5.
• Dual antiplatelet therapy (DAPT) is a cornerstone of treatment during and after percutaneous coronary interventions with DES implantation, and its duration is a critical factor in preventing stent thrombosis and major adverse cardiac and cerebrovascular events (MACCE) 3, 4, 6.

Choice of Stent

• DES are associated with lower rates of stent thrombosis and MACCE compared to BMS, especially in patients who receive extended DAPT 5, 7.
• BMS may be preferred in patients who require shorter-duration DAPT or have a high bleeding risk, but DES optimized for biocompatibility may be a better option even with a single month of DAPT 7.

Antiplatelet Therapy

• The optimal duration of DAPT after percutaneous coronary intervention with DES remains uncertain, but extended-term DAPT (>12 months) is associated with a reduced risk of myocardial infarction at the expense of more bleeding events 6.
• Short-term DAPT (<6 months) followed by aspirin or P2Y12 inhibitor monotherapy may be a viable option for reducing major bleeding without increasing the risk of ischemic events 6.
• Triple antithrombotic therapy (OAC + DAPT) may be necessary in patients with mechanical heart valves and DES, with a target INR of 2.0-2.5 4.

Management of Patients with Cardiac Stents

• Patients with DES should be managed with extended DAPT, especially if they have a high risk of stent thrombosis or MACCE 3, 5, 6.
• Patients with BMS may require shorter-duration DAPT, but the risk of stent thrombosis and MACCE should be carefully weighed against the risk of bleeding 3, 7.
• Patients with mechanical heart valves and DES require careful management of their antithrombotic therapy, with consideration of triple antithrombotic therapy and close monitoring of their INR 4.