What are the guidelines for antiplatelet therapy in patients post Percutaneous Transluminal Coronary Angioplasty (PTCA)?

Antiplatelet Therapy Guidelines for Post-PTCA Patients

In patients who have undergone Percutaneous Transluminal Coronary Angioplasty (PTCA), dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor should be administered for at least 12 months for those with acute coronary syndrome (ACS), while patients with stable ischemic heart disease (SIHD) require at least 1 month of DAPT after bare metal stent (BMS) or at least 6 months after drug-eluting stent (DES) implantation. 1

General Recommendations for DAPT After PTCA

Duration of DAPT Based on Clinical Presentation

• For patients with ACS (STEMI or NSTE-ACS) treated with coronary stent implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months 1
• For patients with stable coronary artery disease receiving DES, clopidogrel should be given for at least 6 months 1
• For patients with stable coronary artery disease receiving BMS, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months 1
• After completion of the recommended DAPT duration, lifelong aspirin 75-100 mg daily is recommended 1

P2Y12 Inhibitor Selection

• In ACS patients, ticagrelor is reasonable to use in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 1
• In ACS patients who are not at high risk for bleeding complications and do not have a history of stroke or TIA, prasugrel is reasonable to choose over clopidogrel 1
• Prasugrel should not be administered to patients with a prior history of stroke or TIA 1
• In stable coronary artery disease patients, clopidogrel is the P2Y12 inhibitor of choice 1

Special Considerations

Bleeding Risk Management

• In selected patients undergoing PCI, shorter-duration DAPT (1 to 3 months) is reasonable with subsequent transition to P2Y12 inhibitor monotherapy to reduce bleeding events 1
• If the risk of bleeding outweighs the anticipated benefit of recommended DAPT duration, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy may be reasonable 1
• In patients at high risk of gastrointestinal bleeding who require DAPT, proton pump inhibitors should be used 1

Extended DAPT Considerations

• In ACS patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation of DAPT for longer than 12 months may be reasonable 1
• In patients with prior MI who are at high risk of severe bleeding, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered 1
• In selected patients at high ischemic risk without high bleeding risk, adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered 1

DAPT After CABG

• In patients with ACS being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS 1
• In patients on P2Y12 inhibitors who need non-emergent cardiac surgery, postponing surgery is recommended for at least 3 days after discontinuation of ticagrelor, at least 5 days after clopidogrel, and at least 7 days after prasugrel 1

Emerging Strategies

• In patients who have tolerated ticagrelor-based DAPT without bleeding complications, ticagrelor monotherapy 90 mg twice daily may be considered as an alternative to dual or other single antiplatelet therapy 1
• Recent evidence suggests that P2Y12 inhibitor monotherapy after a short duration of DAPT may be a viable strategy to reduce bleeding while maintaining protection against ischemic events 2, 3

Common Pitfalls and Caveats

• Premature discontinuation of DAPT significantly increases the risk of stent thrombosis, particularly within the first month after stent implantation 1
• Patients should be counseled on the importance of compliance with DAPT and that therapy should not be discontinued before discussion with their cardiologist 1
• The decision to extend DAPT beyond the recommended duration should carefully balance individual ischemic and bleeding risks 4, 5
• Platelet function testing may be considered to guide the decision on the timing of cardiac surgery in patients who have recently received P2Y12 inhibitors 1
• Routine use of platelet function testing or genetic testing is not recommended, but selective use may be considered for DAPT de-escalation 6

By following these evidence-based guidelines for antiplatelet therapy after PTCA, clinicians can optimize outcomes by reducing both ischemic complications and bleeding risks in their patients.