Should a patient with a history of STEMI and multiple DES continue taking aspirin and clopidogrel?

Dual Antiplatelet Therapy Recommendation for Patient with STEMI and Multiple DES

Recommendation

Continue both clopidogrel and aspirin for this patient who had STEMI with multiple drug-eluting stents (DES) placed one year ago, including in the left main coronary artery. 1

Rationale for Continued Dual Antiplatelet Therapy

Guideline-Based Recommendations

• The 2013 ACCF/AHA guidelines for STEMI management recommend continuing dual antiplatelet therapy (DAPT) for at least 12 months in patients who receive DES 1
• For patients with DES placement, especially in high-risk anatomical locations (such as left main coronary artery), continuation of DAPT beyond 12 months may be considered (Class IIb recommendation) 1
• The patient has several high-risk features that warrant consideration for extended DAPT:
  • Multiple stents (three DES)
  • Left main coronary artery stenting
  • Complex multi-vessel disease
  • History of smoking and multiple cardiovascular risk factors

Safety Considerations

• The patient has tolerated both aspirin and clopidogrel without any bleeding complaints for the past year
• The benefit of continued DAPT likely outweighs the bleeding risk in this particular case

Medication Specifics

Aspirin Therapy

• Continue low-dose aspirin (81 mg daily) indefinitely 1
• Lower maintenance dose (81 mg) is preferred over higher doses to reduce bleeding risk while maintaining efficacy 1, 2

P2Y12 Inhibitor Therapy

• Continue clopidogrel 75 mg daily 1
• For patients with DES placement in high-risk anatomical locations (like left main coronary artery), extended therapy beyond 12 months may be beneficial 1

Special Considerations for This Patient

High-Risk Anatomical Features

• Left main coronary artery stenting carries higher risk of adverse events if stent thrombosis occurs
• Multiple stents (three DES) with overlapping segments increases thrombotic risk
• The patient has multivessel coronary artery disease, indicating extensive atherosclerotic burden

Risk Factor Profile

• The patient has multiple cardiovascular risk factors (hypertension, hyperlipidemia, smoking history)
• History of STEMI indicates high-risk status for future cardiovascular events

Potential Pitfalls and Caveats

Bleeding Risk Assessment

• Regular assessment for bleeding complications is essential during extended DAPT
• If significant bleeding occurs, reevaluation of antiplatelet strategy would be necessary
• Consider adding a proton pump inhibitor if the patient develops GI symptoms

Medication Adherence

• Emphasize the importance of medication adherence to prevent stent thrombosis
• Abrupt discontinuation of antiplatelet therapy significantly increases risk of stent thrombosis 3
• Any planned surgical procedures should involve cardiology consultation before stopping antiplatelet therapy

Alternative Approaches (Not Recommended in This Case)

Discontinuing Clopidogrel

• While some patients may transition to aspirin monotherapy after 12 months, this patient's complex coronary anatomy (left main stenting) and multiple DES placement suggest benefit from continued DAPT

Switching to Different P2Y12 Inhibitor

• No evidence supports switching from clopidogrel to prasugrel at this time point if the patient has tolerated clopidogrel well 4

Discontinuing Both Medications

• Discontinuing both antiplatelet agents would place the patient at high risk for stent thrombosis and is contraindicated 1

In summary, based on the patient's complex coronary anatomy with left main stenting, multiple DES placement, and good tolerance of current therapy, continuing both aspirin 81 mg daily and clopidogrel 75 mg daily is the most appropriate recommendation at this time.