What medications are recommended for patients after percutaneous coronary intervention (PCI)?

Medication Recommendations After Percutaneous Coronary Intervention (PCI)

For patients after PCI, dual antiplatelet therapy (DAPT) consisting of aspirin 75-100 mg and clopidogrel 75 mg daily for up to 6 months is recommended as the default antithrombotic strategy, with adjustments based on bleeding and ischemic risk. 1

Antiplatelet Therapy Recommendations

Standard DAPT Regimen

• Aspirin: 75-100 mg daily lifelong after PCI 1, 2
• P2Y12 inhibitor: Typically clopidogrel 75 mg daily 1
• Duration:
  • 6 months for chronic coronary syndrome (CCS) patients 1, 2
  • 12 months for acute coronary syndrome (ACS) patients 1, 2

DAPT Duration Adjustments

• High bleeding risk patients: Discontinue DAPT after 1-3 months and continue with single antiplatelet therapy 1, 2
• Patients neither at high bleeding nor high ischemic risk: Consider stopping DAPT after 1-3 months 1, 3
• Selected patients undergoing PCI: Shorter-duration DAPT (1-3 months) with subsequent transition to P2Y12 inhibitor monotherapy is reasonable to reduce bleeding risk 1, 3

P2Y12 Inhibitor Selection

1. Clopidogrel: Standard choice for CCS patients 1
2. Prasugrel or Ticagrelor: Consider for ACS patients or high-thrombotic risk stenting (complex left main stem, 2-stent bifurcation, suboptimal stenting result, prior stent thrombosis) 1, 4
   • Caution: Prasugrel is contraindicated in patients with history of TIA/stroke 4
   • Age consideration: Prasugrel generally not recommended in patients ≥75 years due to increased bleeding risk 4

Special Populations

Patients Requiring Oral Anticoagulation

• After uncomplicated PCI:
  • Early cessation of aspirin (≤1 week)
  • Continue OAC and clopidogrel for 6 months (if not at high ischemic risk) or 12 months (if at high ischemic risk)
  • Then OAC alone 1, 2, 5
• DOAC preferred over VKA when eligible 1
• Triple therapy (aspirin + P2Y12 inhibitor + OAC) should be limited to shortest necessary duration 5

Post-CABG Patients

• Initiate aspirin post-operatively as soon as there is no concern over bleeding 1
• Resume P2Y12 inhibitor post-operatively to complete recommended DAPT duration 2

Bleeding Risk Management

• Proton pump inhibitor: Recommended in patients at increased risk of gastrointestinal bleeding for the duration of combined antithrombotic therapy 1, 2
• For patients <60 kg: Consider lowering prasugrel maintenance dose to 5 mg due to increased bleeding risk 4

Long-Term Antiplatelet Therapy

• After completing DAPT, continue with aspirin 75-100 mg daily lifelong 1, 2
• Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy 1, 2

Emerging Strategies

• Recent evidence suggests that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and bleeding without differences in other outcomes 3, 6
• P2Y12 inhibitor monotherapy after short DAPT is showing promise as an alternative strategy to traditional DAPT 3, 7

Common Pitfalls and Caveats

1. Premature DAPT discontinuation: Increases risk of stent thrombosis, particularly in first month after PCI
2. Extended DAPT without consideration of bleeding risk: Can lead to unnecessary bleeding complications
3. Using prasugrel in patients with history of stroke/TIA: Contraindicated due to increased bleeding risk 4
4. Failure to adjust therapy for high bleeding risk patients: Consider shorter DAPT duration (1-3 months)
5. Inadequate gastroprotection: Always consider PPI for patients on DAPT, especially those with risk factors for GI bleeding 1

The optimal antiplatelet regimen after PCI requires balancing ischemic protection against bleeding risk, with recent evidence supporting shorter DAPT durations with subsequent P2Y12 inhibitor monotherapy in many patients.