When should a patient with a drug-eluting stent (DES) placed in the mid left anterior descending artery (LAD) stop taking Plavix (clopidogrel)?

Duration of Clopidogrel Therapy After DES Placement in Mid LAD

For a patient with a drug-eluting stent (DES) placed in the mid LAD in April 2025, clopidogrel should be given for at least 6 months, with discontinuation appropriate after October 2025 if there are no high-risk features. 1

Evidence-Based Recommendations for DES and Clopidogrel

The 2016 ACC/AHA guidelines provide clear recommendations regarding the duration of dual antiplatelet therapy (DAPT) after DES implantation:

• For patients with stable ischemic heart disease (SIHD) treated with DAPT after DES implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for at least 6 months (Class I, Level of Evidence: B-R) 1
• After the minimum 6-month period, patients may safely discontinue clopidogrel while continuing aspirin indefinitely 1
• The recommended daily aspirin dose is 81 mg (range 75-100 mg) 1

Decision Algorithm for DAPT Duration

1. Minimum required duration: 6 months of clopidogrel for DES in stable coronary artery disease 1
2. Consider extended therapy (beyond 6 months) if:
   • Patient has tolerated DAPT without bleeding complications
   • Patient is not at high bleeding risk (no prior bleeding on DAPT, no coagulopathy, no oral anticoagulant use)
   • Extended therapy may be reasonable in these cases (Class IIb recommendation) 1
3. Consider shorter duration (3 months) only if:
   • Patient develops high bleeding risk
   • Patient requires oral anticoagulant therapy
   • Patient is at high risk of severe bleeding complications
   • Patient develops significant overt bleeding 1

Important Clinical Considerations

• Premature discontinuation of DAPT significantly increases the risk of stent thrombosis, which carries a high risk of myocardial infarction or death 2
• The FDA label for clopidogrel warns that discontinuation increases cardiovascular event risk and recommends restarting as soon as possible if temporarily discontinued 3
• After completing the recommended duration of DAPT, patients should continue aspirin 81 mg daily indefinitely 1

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping clopidogrel before 6 months significantly increases stent thrombosis risk
2. Unnecessary prolongation: Continuing DAPT beyond recommended duration without clear indication increases bleeding risk 2
3. Stopping both agents simultaneously: This should never be done in the first months after stenting unless absolutely necessary 2
4. Failure to reassess risk: Both bleeding and ischemic risks can change over time and should be periodically reassessed 2

For this specific patient with a DES placed in mid LAD in April 2025, clopidogrel should be continued until at least October 2025 (6 months), after which it may be discontinued while continuing aspirin indefinitely, assuming no high-risk features that would warrant extended therapy.