What is the recommended antiplatelet therapy for patients with stents, such as Plavix (clopidogrel) and Eliquis (apixaban)?

Recommended Antiplatelet Therapy for Patients with Stents

For patients with coronary stents, dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor is recommended, with specific duration based on clinical presentation and stent type. 1, 2

Standard DAPT Recommendations

For Stable Coronary Artery Disease (SCAD) with Stent Placement:

• First-line therapy: Aspirin (75-100mg daily) plus clopidogrel (600mg loading dose, 75mg daily maintenance)
• Duration: 6 months generally recommended for drug-eluting stents 1
• Duration modifications:
  • 3 months for patients at high bleeding risk (PRECISE-DAPT score ≥25) 1
  • Extended therapy (up to 30 months) may be considered in patients with low bleeding risk but high thrombotic risk 1
  • 1 month may be considered when 3-month DAPT poses safety concerns 1

For Acute Coronary Syndrome (ACS) with Stent Placement:

• First-line therapy: Aspirin (75-100mg daily) plus ticagrelor (180mg loading dose, 90mg twice daily) 1, 2
• Alternative: Aspirin plus prasugrel (60mg loading dose, 10mg daily) for P2Y12-naïve patients 1
• Duration: 12 months is recommended 1, 2

For ACS with Medical Management (No Stent):

• First-line therapy: Aspirin plus ticagrelor for 12 months 1
• Alternative: Aspirin plus clopidogrel if bleeding risk outweighs ischemic benefit 1
• Prasugrel is not recommended in medically managed ACS patients 1

Important Considerations

P2Y12 Inhibitor Selection:

1. Ticagrelor: Preferred in ACS regardless of initial treatment strategy 1
2. Prasugrel: Recommended for ACS patients undergoing PCI, but not for medically managed patients 1
3. Clopidogrel: Recommended for stable CAD patients and ACS patients who cannot receive ticagrelor or prasugrel 1

Bleeding Risk Reduction:

• Radial over femoral access for coronary procedures 1
• Low-dose aspirin (75-100mg daily) 1, 2
• Proton pump inhibitor in combination with DAPT 1, 2
• Avoid routine platelet function testing to adjust therapy 1

Common Pitfalls to Avoid:

1. Premature discontinuation: Increases risk of stent thrombosis, MI, and death 2
2. Inappropriate P2Y12 inhibitor selection: Using prasugrel in medically managed ACS patients or in patients with high bleeding risk 1
3. Inadequate assessment of bleeding risk: Failure to adjust DAPT duration based on bleeding risk scores (e.g., PRECISE-DAPT) 1
4. Inappropriate switching between anticoagulants: Generally avoid crossover between anticoagulants, especially between UFH and LMWH 1

Special Situations

Surgery During DAPT:

• If non-urgent surgery is needed, ticagrelor should be discontinued ≥5 days before the procedure 2
• For urgent surgery, the heart team should assess individual bleeding and ischemic risks 2

Switching Between P2Y12 Inhibitors:

• In ACS patients previously on clopidogrel, switching to ticagrelor is recommended early after hospital admission (180mg loading dose) regardless of timing and loading dose of clopidogrel 1

Long-term Management:

• Life-long single antiplatelet therapy (usually aspirin) is recommended after completing DAPT 1
• Patient education about the importance of compliance with antiplatelet therapy is essential 1

Note: Eliquis (apixaban) is an oral anticoagulant, not an antiplatelet agent, and is not typically used as part of standard DAPT for coronary stents unless there are specific indications for anticoagulation (e.g., atrial fibrillation).