What are the American College of Cardiology (ACC) guidelines for anticoagulation and antiplatelet therapy in patients receiving a stent?

ACC Guidelines for Anticoagulation and Stent Management

For patients with coronary stents, dual antiplatelet therapy (DAPT) should be given for at least 12 months after drug-eluting stent (DES) implantation for acute coronary syndrome (ACS), with options including clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily. 1

Standard DAPT Duration Recommendations

For ACS Patients:

• Drug-eluting stents (DES): DAPT for at least 12 months 1
• Bare-metal stents (BMS): DAPT for at least 12 months 1
• After 12 months, continuation of DAPT may be reasonable for patients without high bleeding risk 1

For Non-ACS Patients:

• Drug-eluting stents: DAPT (clopidogrel 75 mg daily) for at least 12 months if not at high bleeding risk 1
• Bare-metal stents: DAPT for a minimum of 1 month and ideally up to 12 months (unless increased bleeding risk; then minimum 2 weeks) 1

Antiplatelet Agent Selection

• Aspirin dosing: 81 mg daily (range 75-100 mg) is recommended over higher maintenance doses 1
• P2Y12 inhibitor options:
  • Clopidogrel 75 mg daily (after 600 mg loading dose)
  • Prasugrel 10 mg daily (after loading dose) - contraindicated in patients with history of stroke/TIA 1
  • Ticagrelor 90 mg twice daily (after 180 mg loading dose) 1, 2

Special Considerations

Patients Requiring Oral Anticoagulation:

• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) significantly increases bleeding risk
• Current recommendation: Aspirin should be discontinued after 1-4 weeks of triple therapy, continuing with a P2Y12 inhibitor (preferably clopidogrel) plus oral anticoagulant 1
• Clopidogrel is the preferred P2Y12 inhibitor in patients requiring anticoagulation 1

High Bleeding Risk Patients:

• Consider shorter DAPT duration (3-6 months) 1
• Academic Research Consortium defines high bleeding risk by specific criteria including age ≥75 years, severe renal disease, anemia, and prior bleeding events 1
• If bleeding risk outweighs benefit of recommended DAPT duration, earlier discontinuation (<12 months) is reasonable 1

Perioperative Management:

• Elective surgery: Defer for 12 months after DES implantation if possible 1
• If surgery cannot be deferred, consider continuing aspirin perioperatively in high-risk patients 1
• For urgent surgery within 1-12 months after stenting, bare-metal stenting with 4-6 weeks of DAPT and continuation of aspirin perioperatively should be considered 1

Preventing Premature DAPT Discontinuation

The ACC emphasizes the critical importance of preventing premature discontinuation of DAPT, which significantly increases the risk of stent thrombosis, myocardial infarction, and death 1. Key recommendations include:

1. Thorough patient education before discharge about the risks of premature discontinuation
2. Instructing patients to contact their cardiologist before stopping any antiplatelet therapy
3. Healthcare providers performing procedures should contact the patient's cardiologist if concerned about bleeding risks
4. Ensuring cost issues don't lead to premature discontinuation

Evolution of Guidelines

The ACC guidelines have evolved from recommending longer DAPT durations with first-generation DES to more nuanced recommendations with newer-generation stents that have lower thrombosis risk 1. The current approach balances ischemic protection against bleeding risk, with decisions based on individual patient factors including:

• Type of stent (DES vs. BMS)
• Clinical presentation (ACS vs. stable CAD)
• Bleeding risk profile
• Concomitant need for anticoagulation

By following these evidence-based guidelines, clinicians can optimize outcomes by reducing both thrombotic and bleeding complications in patients with coronary stents.