What is the recommended treatment after placement of 2 drug-eluting stents (DES) in the left coronary (L Cr) artery?

Dual Antiplatelet Therapy After Drug-Eluting Stent Placement in Left Coronary Artery

After placement of 2 drug-eluting stents (DES) in the left coronary artery, patients should receive dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor for 12 months. 1

Standard DAPT Regimen

• DAPT consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) is the standard of care following DES implantation 2
• For patients with drug-eluting stents, DAPT is recommended for a minimum of 12 months 1, 2
• Aspirin should be continued indefinitely, while the P2Y12 inhibitor is typically discontinued after the recommended DAPT duration unless there are specific indications for prolonged therapy 1

Choice of P2Y12 Inhibitor

• For patients who received DES during an acute coronary syndrome (ACS), more potent P2Y12 inhibitors (ticagrelor or prasugrel) are preferred over clopidogrel 1
• For elective (non-ACS) DES placement, clopidogrel is generally the P2Y12 inhibitor of choice; ticagrelor or prasugrel may be used only if there is a prior history of stent thrombosis while on clopidogrel 1
• Ticagrelor is administered at a dose of 90 mg twice daily for the first year, with consideration for reduced dose (60 mg twice daily) if therapy is extended beyond 12 months 1, 3

Risk of Premature DAPT Discontinuation

• Premature discontinuation of DAPT significantly increases the risk of stent thrombosis, which carries high morbidity and mortality rates 1, 4
• Stent thrombosis occurs in 0.5-2.0% of cases, with higher risk when antiplatelet therapy is interrupted 4
• Elective non-cardiac procedures should be deferred until completion of the recommended DAPT course whenever possible 1

Special Considerations for Surgery During DAPT

• For patients requiring urgent surgery within the DAPT period:
  • Very low bleeding-risk procedures can be undertaken without stopping DAPT 1
  • For low bleeding-risk procedures in patients with low thrombotic risk, the P2Y12 inhibitor may be discontinued 5-7 days pre-operatively while continuing aspirin 1
  • For high bleeding-risk procedures, consultation with a cardiologist is strongly recommended 1

Extended DAPT Beyond 12 Months

• Extended DAPT beyond 12 months may be considered in selected patients with high ischemic risk and low bleeding risk 1, 3
• The decision to extend DAPT should be based on a careful assessment of individual thrombotic and bleeding risks 3
• If extended therapy is chosen after the first year, a reduced dose of ticagrelor (60 mg twice daily) may be considered 3

Bleeding Risk Considerations

• DAPT increases the risk of bleeding, particularly in elderly patients 4
• The PRECISE-DAPT score can help guide DAPT duration based on bleeding risk, with shorter DAPT duration (3-6 months) considered for patients at high bleeding risk 4
• Patients on oral contraceptives or with history of bleeding disorders require special consideration due to increased thrombotic or hemorrhagic risk 1

Monitoring and Compliance

• Regular monitoring for both bleeding and thrombotic complications is essential 4
• Patient education regarding the importance of DAPT adherence is critical to prevent stent thrombosis 1
• Patients should be instructed to consult their cardiologist before discontinuing any antiplatelet medication 1