Duration of Antiplatelet Therapy After Stent Placement
After stent placement, clopidogrel (Plavix) should be continued for at least 1 month after bare-metal stent implantation, 3 months after sirolimus-eluting stent, and 6 months after paclitaxel-eluting stent, while aspirin should be continued indefinitely.
Antiplatelet Therapy Duration Based on Stent Type
Clopidogrel (Plavix)
- Bare-metal stents: Minimum 1 month, ideally up to 12 months 1
- Drug-eluting stents:
Aspirin
- Initial dosing: 162-325 mg daily for at least 1 month after bare-metal stent, 3 months after sirolimus-eluting stent, and 6 months after paclitaxel-eluting stent 1
- Long-term maintenance: 75-162 mg daily indefinitely after the initial period 1, 2
Special Considerations
High Thrombotic Risk Patients
For patients at higher risk of stent thrombosis, longer duration of dual antiplatelet therapy should be maintained. High-risk features include:
- Drug-eluting stents placed within past 6-12 months 2
- History of stent thrombosis 2
- Multiple stents or long stents 2
- Bifurcation stents 2
- Diabetes 2
- Low ejection fraction 2
- Incomplete revascularization 2
Bleeding Risk Management
- For patients with increased bleeding risk, lower-dose aspirin (75-162 mg) is reasonable during the initial period after stent implantation 1
- If active bleeding develops, clopidogrel may be temporarily held while maintaining aspirin, but both medications should never be discontinued simultaneously if the stent was placed within the past year 2
Important Warnings and Precautions
- Early discontinuation risk: Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis (up to sevenfold) 2
- Multidisciplinary approach: Before any planned procedure requiring antiplatelet interruption, a multidisciplinary team meeting should occur to assess individual thrombotic risk versus procedure-specific bleeding risk 2
- Resumption after interruption: If antiplatelet therapy must be interrupted, aspirin should be resumed within 24-48 hours after the procedure unless absolutely contraindicated 2
Long-term Maintenance Therapy
Recent evidence suggests that for long-term maintenance monotherapy (after completing the required dual antiplatelet therapy period), clopidogrel may be superior to aspirin in reducing composite adverse events without increasing bleeding risk 3. However, current guidelines still recommend indefinite aspirin therapy as the standard approach 1.
The risk of stent thrombosis from antiplatelet discontinuation generally outweighs the bleeding risk, even in patients with anemia or other bleeding risk factors 2. Therefore, maintaining appropriate antiplatelet therapy according to the stent type and timing is critical for preventing potentially catastrophic thrombotic complications.