Do you keep someone on Dual Antiplatelet Therapy (DAPT) with aspirin and clopidogrel after Percutaneous Coronary Intervention (PCI) with stents?

Duration of Dual Antiplatelet Therapy After PCI with Stents

For patients who have undergone PCI with stent placement, DAPT consisting of aspirin 75-100 mg and clopidogrel 75 mg daily should be continued for 12 months in patients with acute coronary syndrome (ACS), and for 6 months in patients with chronic coronary syndrome (CCS) who have no indication for oral anticoagulation. 1

Duration Based on Clinical Presentation

Acute Coronary Syndrome (ACS)

• P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months after BMS or DES implantation 1
• In patients who have tolerated DAPT without bleeding complications and who are not at high bleeding risk, continuation beyond 12 months may be reasonable 1, 2
• For ACS patients treated with CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT 1

Chronic Coronary Syndrome (CCS)

• DAPT consisting of aspirin 75-100 mg and clopidogrel 75 mg daily for up to 6 months is the default strategy 1
• In patients at high bleeding risk but not at high ischemic risk, discontinue DAPT after 1-3 months and continue with single antiplatelet therapy 1
• Stopping DAPT after 1-3 months may be considered in patients who are neither at high bleeding nor high ischemic risk 1

P2Y12 Inhibitor Selection

• For ACS patients: Ticagrelor is reasonable to use in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 1
• For ACS patients not at high bleeding risk and without history of stroke/TIA: Prasugrel is reasonable to choose over clopidogrel 1
• Important safety note: Prasugrel should never be administered to patients with prior history of stroke or TIA 1, 3
• For CCS patients undergoing high-thrombotic risk stenting (complex left main, 2-stent bifurcation, suboptimal result, prior stent thrombosis), prasugrel or ticagrelor may be considered instead of clopidogrel for the first month up to 3-6 months 1

Aspirin Dosing

• A daily aspirin dose of 81 mg (range 75-100 mg) is recommended for all patients on DAPT 1
• Low-dose aspirin is preferred over higher doses to reduce bleeding risk while maintaining efficacy 2

Special Considerations

High Bleeding Risk Patients

• In ACS patients with DES who develop high bleeding risk or significant overt bleeding, discontinuation of P2Y12 therapy after 6 months may be reasonable 1
• For patients at high bleeding risk, a proton pump inhibitor is recommended for the duration of DAPT 1

Patients Requiring Oral Anticoagulation

• After uncomplicated PCI in CCS patients with indication for oral anticoagulation:
  • Early cessation of aspirin (≤1 week)
  • Continue OAC and clopidogrel for up to 6 months (if not at high ischemic risk) or up to 12 months (if at high ischemic risk)
  • Then OAC alone 1

Recent Evidence on Shorter DAPT Duration

Recent research has explored shorter DAPT durations. The STOPDAPT-2 trial demonstrated that 1 month of DAPT followed by clopidogrel monotherapy was both non-inferior and superior to 12 months of DAPT for a composite of cardiovascular and bleeding events 4. Similarly, the ITALIC trial showed that 6-month DAPT was non-inferior to 24-month DAPT in aspirin-sensitive patients 5.

Long-term Antiplatelet Therapy After DAPT

After completing the recommended DAPT duration:

• Aspirin 75-100 mg daily is recommended lifelong in patients with prior MI or PCI 1
• Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy 1, 6
• Recent evidence suggests clopidogrel monotherapy may be associated with reductions in MACE and stroke compared to aspirin monotherapy 6

Algorithm for DAPT Duration Decision-Making

1. Determine clinical presentation:

   • ACS → 12 months DAPT
   • CCS → 6 months DAPT

2. Assess bleeding risk:

   • High bleeding risk (prior bleeding on DAPT, coagulopathy, oral anticoagulant use) → Consider shorter duration (1-3 months for CCS, 6 months for ACS)

3. Assess ischemic risk:

   • High ischemic risk (multivessel disease, complex PCI, history of recurrent MI, diabetes) → Consider longer duration if bleeding risk is not high

4. Select appropriate P2Y12 inhibitor:

   • ACS → Consider ticagrelor or prasugrel (if no contraindications)
   • CCS → Clopidogrel is standard
   • High thrombotic risk stenting → Consider more potent P2Y12 inhibitor initially

5. After DAPT completion:

   • Continue single antiplatelet therapy indefinitely (aspirin or clopidogrel)

By following this evidence-based approach to DAPT management after PCI, clinicians can optimize the balance between preventing ischemic events and minimizing bleeding complications.