What is the recommended management plan for a patient with Coronary Artery Disease (CAD) who has been treated with a Drug-Eluting Stent (DES)?

Management of Coronary Artery Disease with Drug-Eluting Stents

Patients with coronary artery disease (CAD) who have received a drug-eluting stent (DES) should receive dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor for at least 12 months to reduce the risk of stent thrombosis, myocardial infarction, and death. 1

Dual Antiplatelet Therapy (DAPT) Recommendations

Initial DAPT Duration

• Patients with DES should receive DAPT for at least 12 months if they are not at high risk for bleeding 1
• DAPT consists of low-dose aspirin (81 mg daily, range 75-100 mg) plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) 1
• For patients with acute coronary syndrome (ACS) treated with DES, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 1
• For ACS patients without high bleeding risk or history of stroke/TIA, prasugrel may be chosen over clopidogrel 1

Extended DAPT Considerations

• In patients who have tolerated DAPT for 12 months without bleeding complications and are not at high bleeding risk, continuation of DAPT beyond 12 months may be reasonable 1
• The decision to extend DAPT should be based on a careful assessment of the benefit/risk ratio, weighing ischemic risk against bleeding risk 1
• The DAPT score can help identify patients who may benefit from extended therapy (score ≥2 suggests favorable benefit/risk ratio for prolonged DAPT) 1

Early Discontinuation Considerations

• For patients who develop high bleeding risk (e.g., need for oral anticoagulant therapy) or significant overt bleeding, discontinuation of P2Y12 inhibitor therapy may be reasonable after 6 months in ACS patients 1
• In stable ischemic heart disease patients with DES who develop high bleeding risk, discontinuation of P2Y12 inhibitor therapy after 3 months may be reasonable 1

Management of Perioperative Period

• Elective surgery should be postponed for 12 months after DES placement if possible 1
• If surgery cannot be deferred, consider continuing aspirin during the perioperative period in high-risk patients with DES 1
• For procedures with significant risk of perioperative bleeding, defer until completion of appropriate DAPT course (12 months for DES) 1
• If P2Y12 inhibitor must be discontinued for surgery, aspirin should be continued if at all possible, and the P2Y12 inhibitor restarted as soon as possible after the procedure 1

Risks of Premature DAPT Discontinuation

• Premature discontinuation of DAPT is the leading independent predictor for stent thrombosis 1
• Stent thrombosis is a catastrophic event with mortality rates of 20-45% 1
• In patients who prematurely discontinue DAPT, stent thrombosis occurs in up to 29% of cases 1
• Late stent thrombosis (1-12 months) occurs in approximately 0.19% of DES patients 1

Long-Term Management Beyond DAPT

• After completion of the recommended DAPT duration, aspirin therapy should be continued indefinitely in patients with CAD 1
• Risk factors for stent thrombosis include: small vessels, multiple lesions, long stents, overlapping stents, ostial or bifurcation lesions, suboptimal stent results, low ejection fraction, advanced age, diabetes mellitus, renal failure, and acute coronary syndrome 1
• Regular follow-up to assess for recurrent symptoms, medication adherence, and management of cardiovascular risk factors is essential 1

Special Considerations

• For patients requiring triple therapy (DAPT plus oral anticoagulation), keep triple therapy duration as short as possible 1
• In patients on triple therapy, clopidogrel is the P2Y12 inhibitor of choice 1
• Newer-generation DES have improved safety profiles and lower risk of stent thrombosis compared to first-generation DES 1
• Prasugrel should not be administered to patients with a prior history of stroke or TIA 1