How long after stent placement should aspirin (acetylsalicylic acid) therapy be continued?

Duration of Aspirin Therapy After Stent Placement

After stent placement, aspirin therapy should be continued indefinitely in all patients if not contraindicated. 1

Aspirin Dosing Recommendations

Initial Period After Stent Placement

• For all post-PCI stented patients, aspirin dosing should follow this pattern:
  • Initial period: 325 mg daily for:
    • At least 1 month after bare-metal stent (BMS) implantation
    • 3 months after sirolimus-eluting stent implantation
    • 6 months after paclitaxel-eluting stent implantation 1

Long-Term Maintenance Therapy

• After the initial period, transition to lower-dose aspirin (75-162 mg daily) indefinitely 1
• 81 mg daily is reasonable as the preferred maintenance dose 1, 2

Dual Antiplatelet Therapy (DAPT) Considerations

Duration of P2Y12 Inhibitor (Clopidogrel, Prasugrel, or Ticagrelor)

• For ACS patients receiving any stent (BMS or DES): at least 12 months 1
• For non-ACS patients receiving DES: at least 12 months if not at high risk of bleeding 1
• For non-ACS patients receiving BMS: minimum 1 month, ideally up to 12 months 1
  • If increased bleeding risk: minimum 2 weeks 1

Continuation Beyond Initial Period

• Continuation of P2Y12 inhibitor beyond 12 months may be considered in patients with DES 1
• Earlier discontinuation of P2Y12 inhibitor therapy (<12 months) is reasonable if bleeding risk outweighs benefit 1

Special Considerations

Bleeding Risk Management

• For patients with concern about bleeding risk, lower-dose aspirin (75-162 mg) is reasonable during the initial period after stent implantation 1
• Low-dose aspirin (81 mg) in combination with clopidogrel does not appear to increase the risk of definite stent thrombosis compared to higher-dose aspirin regimens 3

Patient Education

• Patients should be counseled on the importance of compliance with DAPT
• Therapy should not be discontinued before discussion with their cardiologist 1

Clinical Implications

The indefinite continuation of aspirin therapy after stent placement is crucial for reducing the risk of stent thrombosis and cardiovascular events. While the P2Y12 inhibitor component of DAPT may be discontinued after the recommended duration based on stent type and clinical presentation, aspirin therapy should be maintained indefinitely unless contraindicated.

Early discontinuation of antiplatelet therapy has been associated with increased risk of stent thrombosis and adverse cardiac events 4. The evidence strongly supports that the benefits of long-term aspirin therapy outweigh the risks in patients who have undergone coronary stent placement.

Common Pitfalls to Avoid

1. Premature discontinuation of aspirin therapy
2. Using higher maintenance doses than necessary (>162 mg), which may increase bleeding risk without additional benefit
3. Failing to transition from higher initial doses to lower maintenance doses after the appropriate initial period
4. Not considering bleeding risk when determining aspirin dosage
5. Discontinuing antiplatelet therapy before elective procedures without consulting the patient's cardiologist