Should Dual Antiplatelet Therapy (DAPT) be discontinued during Percutaneous Coronary Intervention (PCI) placement?

Dual Antiplatelet Therapy During PCI Placement

DAPT should not be discontinued during PCI placement as it is essential for preventing thrombotic complications during the procedure. 1

Rationale for Continuing DAPT During PCI

• P2Y12 inhibitor therapy is recommended during PCI with a Class I, Level A recommendation according to both ACC/AHA and ESC guidelines 1
• Discontinuation of antiplatelet therapy during PCI would increase the risk of acute stent thrombosis, which carries significant morbidity and mortality 1
• For patients undergoing PCI, guidelines specifically recommend the continuation of P2Y12 inhibitors throughout the procedure to maintain adequate platelet inhibition 1

Antiplatelet Management During PCI

• For patients already on DAPT who are undergoing PCI:
  • Continue aspirin (75-100 mg) without interruption 1
  • Continue the P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) without interruption 1
• For patients not previously on DAPT who are undergoing PCI:
  • Loading dose of aspirin (325 mg orally or 75-250 mg IV) is recommended 1
  • Loading dose of clopidogrel (600 mg) is recommended for elective stenting 1
  • In high-risk situations (e.g., left main stenting), prasugrel or ticagrelor may be considered 1

Duration of DAPT After PCI

While the question specifically addresses DAPT during PCI placement, it's important to note the recommended duration after the procedure:

• For stable coronary artery disease (SCAD) with DES placement: 6 months of DAPT is generally recommended 1
• For patients at high bleeding risk: DAPT duration can be shortened to 1-3 months 1, 2
• For patients at high thrombotic risk: DAPT may be extended up to 30 months 1
• For acute coronary syndrome (ACS): DAPT is recommended for 12 months 1

Special Considerations

• If urgent surgery is needed within 30 days of DES placement, DAPT should be continued unless the bleeding risk significantly outweighs the benefit of stent thrombosis prevention 1
• For patients on anticoagulation who require PCI, triple therapy (DAPT plus anticoagulant) is initially recommended, followed by early cessation of aspirin (≤1 week) and continuation of OAC plus clopidogrel 1
• Recent meta-analyses suggest that shorter DAPT durations (1-3 months) followed by P2Y12 inhibitor monotherapy may reduce bleeding complications without increasing ischemic events 3, 4, 5, 2

Potential Pitfalls to Avoid

• Never discontinue both antiplatelet agents simultaneously due to the high risk of stent thrombosis 6
• Avoid premature discontinuation of DAPT after PCI as it increases the risk of stent thrombosis, myocardial infarction, and death 7
• Recognize that lapses in antiplatelet therapy should be avoided, and if temporary discontinuation is necessary due to adverse events, therapy should be restarted as soon as possible 7

In conclusion, DAPT should be maintained during PCI placement to minimize the risk of thrombotic complications. The focus should be on appropriate loading doses for patients not already on DAPT and continuing therapy in those already taking antiplatelet medications.