What is the recommended antiplatelet therapy for a patient with a stent placed in 2017?

Recommended Antiplatelet Therapy for a Patient with a Stent Placed in 2017

For a patient with a stent placed in 2017, single antiplatelet therapy with aspirin 75-100 mg daily is the recommended maintenance therapy at this point, as the standard dual antiplatelet therapy (DAPT) duration of 12 months has been exceeded. 1

Determining Factors for Antiplatelet Therapy

The appropriate antiplatelet therapy depends on several key factors:

1. Time since stent placement:

   • For a stent placed in 2017 (>5 years ago), the standard 12-month DAPT period has been completed
   • The risk of very late stent thrombosis (VLST) is now significantly lower than in the first year

2. Type of stent:

   • Drug-eluting stent (DES): Standard DAPT duration is 12 months
   • Bare metal stent (BMS): Standard DAPT duration is 1-6 months
   • Both types require lifelong aspirin therapy after completing DAPT 1

3. Clinical presentation at time of stenting:

   • Acute Coronary Syndrome (ACS): 12 months of DAPT was recommended
   • Stable Coronary Artery Disease (SCAD): 1-6 months of DAPT was recommended 1

Current Recommendations

For patients beyond 12 months post-stenting (as in this case):

• Continue aspirin 75-100 mg daily indefinitely 1, 2
• Discontinue P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) unless specific high ischemic risk features are present

Special considerations that might warrant extended DAPT beyond 12 months:

• History of stent thrombosis
• Complex PCI (multiple stents, bifurcation stenting, long stents)
• Peripheral arterial disease
• Recurrent ischemic events
• High-risk anatomical features (left main, proximal LAD, or last patent vessel)

Bleeding Risk Considerations

When considering antiplatelet therapy, bleeding risk must be balanced against thrombotic risk:

• Low-dose aspirin (75-100 mg) is recommended to minimize bleeding risk 1, 3
• Proton pump inhibitors should be considered in patients at high risk for gastrointestinal bleeding 1

Special Situations

1. If the patient requires oral anticoagulation (e.g., for atrial fibrillation):

   • At this point (>5 years post-stenting), oral anticoagulation plus aspirin is generally sufficient
   • Clopidogrel would be preferred if a P2Y12 inhibitor is needed 1, 4

2. If the patient requires non-cardiac surgery:

   • At >5 years post-stenting, aspirin can typically be continued perioperatively unless bleeding risk is prohibitively high 1

Common Pitfalls to Avoid

1. Unnecessary continuation of DAPT beyond recommended duration - increases bleeding risk without clear ischemic benefit
2. Premature discontinuation of aspirin - aspirin should be continued indefinitely
3. Failure to reassess bleeding and ischemic risks periodically - these can change over time
4. Not considering drug interactions - particularly important if the patient is on multiple medications

While some research has explored alternate-day clopidogrel as a strategy to prevent very late stent thrombosis 5, this approach is not currently recommended in major guidelines and should not replace standard therapy based on the European Society of Cardiology guidelines 1.