Should I discontinue Dual Antiplatelet Therapy (DAPT) before a teeth extraction in a patient 6 months post Percutaneous Coronary Intervention (PCI)?

Management of DAPT Before Teeth Extraction in Post-PCI Patient

For a patient 6 months after PCI on DAPT, aspirin should be continued while the P2Y12 inhibitor may be temporarily discontinued before teeth extraction if necessary, based on individual bleeding risk assessment. 1

Risk Assessment Framework

The management of antiplatelet therapy before dental procedures requires balancing two competing risks:

1. Thrombotic risk: Premature discontinuation of DAPT increases risk of stent thrombosis
2. Bleeding risk: Continuing full DAPT may increase procedural bleeding

Key Considerations:

• Time since PCI: 6 months is a critical timepoint

  • At 6 months post-PCI for stable CAD, the patient has completed the minimum recommended DAPT duration 1
  • Risk of stent thrombosis is significantly lower than during the first 3 months 1

• Type of dental procedure: Tooth extraction has moderate bleeding risk but is generally manageable with local hemostatic measures

Recommended Approach

For most patients:

1. Continue aspirin 81mg daily without interruption 1
2. Consider temporary interruption of P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) 3-5 days before the procedure if bleeding risk is high 1
3. Resume P2Y12 inhibitor as soon as hemostasis is achieved, typically within 24-48 hours 1

For high thrombotic risk patients:

(Recent ACS, complex PCI, multiple stents, diabetes)

1. Continue both aspirin and P2Y12 inhibitor if possible 1, 2
2. Implement additional local hemostatic measures during the procedure:
   • Local pressure
   • Topical hemostatic agents
   • Suturing
   • Tranexamic acid mouthwash

Important Considerations

• Consult with cardiologist if the patient had PCI for ACS (rather than stable CAD), as these patients have higher thrombotic risk and may benefit from continued DAPT 1

• Local hemostatic measures are often sufficient to control bleeding even with continued DAPT 2

• Avoid complete DAPT discontinuation when possible, as this significantly increases stent thrombosis risk 1

Common Pitfalls to Avoid

1. Unnecessarily stopping both antiplatelet agents - this dramatically increases thrombotic risk
2. Failing to resume P2Y12 inhibitor promptly after the procedure
3. Not considering the indication for PCI (ACS vs. stable CAD) in risk assessment
4. Overlooking local hemostatic measures that can allow continuation of DAPT

Follow-up Recommendations

• Schedule the dental procedure early in the day and week to allow for management of any delayed bleeding
• Provide clear instructions to the patient about when to resume the P2Y12 inhibitor
• Ensure the patient has contact information for emergencies related to either bleeding or cardiac symptoms

By following this approach, you can minimize both thrombotic and bleeding risks in this post-PCI patient requiring dental extraction.