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

Management of DAPT Before Tooth Extraction 6 Months After PCI

For a patient 6 months after PCI on DAPT, you should continue aspirin without interruption while the P2Y12 inhibitor may be temporarily discontinued 3-5 days before tooth extraction if bleeding risk is high. 1

Risk Assessment and Decision Algorithm

Time Since PCI Considerations

• At 6 months post-PCI for stable CAD, the patient has completed the minimum recommended DAPT duration (6 months) according to ACC/AHA guidelines 2
• The risk of stent thrombosis is significantly lower than during the first 3 months post-PCI 1
• The 2016 ACC/AHA update recommends aspirin indefinitely and clopidogrel for 6 months after drug-eluting stent implantation 2

Management Strategy Based on Clinical Scenario

1. For most patients with stable CAD at 6 months post-PCI:

   • Continue aspirin 81mg daily without interruption 1
   • Consider temporary interruption of P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) 3-5 days before the procedure 1
   • Resume P2Y12 inhibitor within 24-48 hours after the procedure once hemostasis is achieved 1

2. For high thrombotic risk patients (recent ACS, complex PCI, multiple stents, diabetes):

   • Continue both aspirin and P2Y12 inhibitor if possible 1
   • Implement additional local hemostatic measures during the procedure 1
   • If bleeding risk is extremely high, consider consulting with cardiologist before any medication changes 1

Practical Considerations

Local Hemostatic Measures

• Local hemostatic measures are often sufficient to control bleeding even with continued DAPT 1
• Consider using:
  • Local pressure
  • Topical hemostatic agents
  • Suturing
  • Tranexamic acid mouthwash

Important Caveats

• Complete discontinuation of DAPT significantly increases stent thrombosis risk and should be avoided 1
• Thienopyridines (like prasugrel) inhibit platelet aggregation for the lifetime of the platelet (7-10 days), so withholding a dose will not immediately reverse bleeding risk 3
• If bleeding occurs, platelet transfusions within 6 hours of loading dose or 4 hours of maintenance dose may be less effective 3

Recent Evidence Supporting Decision

• Recent meta-analyses show that shorter DAPT durations (1-3 months) followed by P2Y12 inhibitor monotherapy reduce bleeding risk without increasing thrombotic events compared to 12-month DAPT 4, 5
• In patients who have completed 6 months of DAPT after PCI for stable CAD, the thrombotic risk is substantially lower than in the early post-PCI period 2, 1

Follow-up Recommendations

• 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
• Schedule follow-up to assess healing and medication adherence