How many years should antiplatelet therapy and statin therapy be continued after Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG)?

Duration of Antiplatelet and Statin Therapy After PCI and CABG

For patients who have undergone PCI or CABG, aspirin should be continued indefinitely, while P2Y12 inhibitor therapy duration varies based on clinical context - generally 12 months for ACS patients and 6 months for stable coronary disease patients, with statin therapy continued indefinitely for secondary prevention. 1

Antiplatelet Therapy Duration

After PCI:

1. Aspirin therapy:

   • Should be continued indefinitely in all patients 1
   • Low-dose aspirin (81mg daily) is preferred over higher doses 1, 2

2. P2Y12 inhibitor therapy (clopidogrel, ticagrelor, or prasugrel):

   • For ACS patients (NSTE-ACS or STEMI):

     • At least 12 months of P2Y12 inhibitor therapy 1, 2
     • Ticagrelor is reasonable to use in preference to clopidogrel 1

   • For stable ischemic heart disease (SIHD):

     • With DES: At least 6 months of clopidogrel 1, 2
     • With BMS: Minimum 1 month of clopidogrel, ideally up to 12 months 1

3. Extended DAPT beyond standard duration:

   • May be reasonable in patients who have tolerated DAPT without bleeding complications 1
   • Most beneficial for patients with high ischemic risk and low bleeding risk 1, 3
   • The "DAPT score" can help determine benefit/risk ratio (score ≥2 favors prolonged DAPT) 1

After CABG:

1. Aspirin therapy:

   • Should be continued indefinitely 1

2. P2Y12 inhibitor therapy:

   • After CABG for ACS: Resume P2Y12 inhibitor post-operatively and continue for at least 12 months 1
   • For SIHD: Clopidogrel for 12 months may be reasonable 1
   • After recent PCI: Continue P2Y12 inhibitor for the recommended duration after PCI 1

Statin Therapy Duration

While the question specifically asks about antiplatelet and statin therapy duration, it's important to note that:

• Statin therapy should be continued indefinitely in patients who have undergone PCI or CABG for secondary prevention of cardiovascular events
• High-intensity statin therapy is recommended for most patients with established coronary artery disease

Special Considerations

Bleeding Risk Assessment:

• If bleeding risk outweighs ischemic benefit, earlier discontinuation of P2Y12 inhibitor may be reasonable:
  • After 3 months for SIHD patients with DES
  • After 6 months for ACS patients with DES 1

High Ischemic Risk Factors:

• Prior stent thrombosis
• Diabetes mellitus
• Multiple stents
• Complex lesions (bifurcation, left main)
• Current smoking
• History of recurrent MI 1, 2

High Bleeding Risk Factors:

• Advanced age
• Oral anticoagulant use
• History of bleeding
• Coagulopathy
• End-stage renal failure 2

Important Caveats

1. Premature discontinuation risks: Stopping DAPT prematurely significantly increases the risk of stent thrombosis, MI, and death 2, 4

2. Patient counseling: Patients should be explicitly counseled about the importance of adherence to DAPT and warned not to discontinue therapy without consulting their cardiologist 1, 2

3. Perioperative management: Elective procedures should ideally be delayed until completion of the recommended DAPT duration 2

4. Proton pump inhibitors: Should be used in patients with history of GI bleeding or increased risk of GI bleeding who require DAPT 1, 2

5. Off-pump CABG considerations: DAPT may provide additional benefits in patients undergoing off-pump CABG in terms of graft patency 5, 6

The evidence strongly supports lifelong aspirin therapy with time-limited P2Y12 inhibitor therapy based on clinical context, with statin therapy continued indefinitely for secondary prevention in patients with established coronary artery disease who have undergone PCI or CABG.