How long should a patient be off aspirin (acetylsalicylic acid) after having stents placed 3 years ago due to bleeding risk?

Duration of Aspirin Therapy After Coronary Stent Placement

For patients with coronary stents placed 3 years ago, aspirin therapy should be continued indefinitely (lifelong) at a dose of 75-162 mg daily unless there is a significant bleeding risk that outweighs the cardiovascular benefit.

Evidence-Based Recommendations for Aspirin Therapy

• After coronary stent placement, aspirin 75-162 mg daily should be continued indefinitely in all patients if not contraindicated 1
• For all post-PCI stented patients, aspirin is recommended lifelong after the initial period of dual antiplatelet therapy (DAPT) 1
• The 2024 ESC guidelines for chronic coronary syndromes specifically recommend aspirin 75-100 mg daily lifelong after an initial period of DAPT in patients with prior MI or remote PCI 1

Duration of Dual Antiplatelet Therapy (Historical Context)

• Initially after stent placement, DAPT (aspirin plus clopidogrel) is recommended for a specific duration depending on stent type 1:
  • At least 1 month for bare-metal stents
  • At least 3 months for sirolimus-eluting stents
  • At least 6 months for paclitaxel-eluting stents
• After this initial DAPT period, aspirin monotherapy should be continued indefinitely 1

Current Recommendations for Long-Term Therapy (3+ Years Post-Stent)

• For patients who are 3 years post-stent placement (as in this case), the recommended therapy is single antiplatelet therapy with aspirin 75-162 mg daily continued indefinitely 1
• The American Heart Association/American College of Cardiology guidelines consistently recommend lifelong aspirin therapy after the initial DAPT period 1

Considerations for Bleeding Risk

• If there is concern about bleeding risk, a lower dose of aspirin (75-81 mg daily) is reasonable for long-term therapy 1
• For patients at high bleeding risk who require temporary interruption of aspirin (e.g., for surgery):
  • For low-to-intermediate risk noncardiac surgery more than 1 year after stent placement, recent evidence suggests that temporarily discontinuing aspirin 5 days before surgery may be considered with resumption within 48 hours after surgery 2
  • However, for high-risk patients with drug-eluting stents undergoing surgery, continuation of aspirin during the perioperative period should be considered 3

Specific Guidance for Bleeding Risk Scenarios

• If bleeding risk is temporary (e.g., upcoming surgery), aspirin can be temporarily discontinued 5 days before the procedure and resumed within 48 hours afterward 2
• If bleeding risk is persistent and severe, the decision to discontinue aspirin should be made after careful consideration of the thrombotic risk versus bleeding risk 1
• In patients with high bleeding risk but also high ischemic risk, maintaining the lowest effective dose of aspirin (75 mg daily) may be the optimal approach 1

Important Clinical Considerations

• Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis, myocardial infarction, and death 3
• Patients should be counseled not to discontinue aspirin therapy without discussing with their cardiologist 4
• For patients with both high bleeding and high thrombotic risks, cardiology consultation is strongly recommended before making changes to aspirin therapy 1, 3