What is the recommended duration and regimen of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor, such as clopidogrel, for a patient who has undergone angioplasty due to stent restenosis?

Dual Antiplatelet Therapy After Angioplasty for Stent Restenosis

For patients who have undergone angioplasty due to stent restenosis, dual antiplatelet therapy (DAPT) with aspirin should be continued indefinitely, and a P2Y12 inhibitor (clopidogrel) should be given for at least 6 months. 1

Standard DAPT Recommendations

• After angioplasty with drug-eluting stent (DES) implantation for stent restenosis, P2Y12 inhibitor therapy (clopidogrel) should be given for at least 6 months 1
• Aspirin should be continued indefinitely at a daily dose of 81 mg (range 75-100 mg) 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

Duration Modifications Based on Risk Profile

Extended DAPT Duration

• In patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation of DAPT beyond 6 months may be reasonable 1
• The decision to extend DAPT should be based on the patient's individual ischemic and bleeding risk profile 1

Shortened DAPT Duration

• In patients who develop high bleeding risk (e.g., treatment with oral anticoagulant therapy) or significant overt bleeding, discontinuation of P2Y12 inhibitor therapy after 3 months may be reasonable 1
• For patients at very high bleeding risk, discontinuation of P2Y12 inhibitor therapy after 1 month may be considered in select cases 1

P2Y12 Inhibitor Selection

• Clopidogrel 75 mg daily is the standard P2Y12 inhibitor for patients undergoing angioplasty for stent restenosis 1, 2
• Prasugrel and ticagrelor are generally reserved for acute coronary syndrome (ACS) presentations and are not typically recommended for stable patients with stent restenosis 1, 3
• Prasugrel should not be administered to patients with prior history of stroke or transient ischemic attack 1

Practical Considerations

• Proton pump inhibitors (PPIs) should be used in patients with a history of prior gastrointestinal bleeding who require DAPT 1
• PPIs are reasonable in patients with increased risk of gastrointestinal bleeding (advanced age, concomitant use of warfarin, steroids, NSAIDs, Helicobacter pylori infection) 1
• Routine use of PPIs is not recommended for patients at low risk of gastrointestinal bleeding 1

Common Pitfalls and Caveats

• Premature discontinuation of DAPT is associated with increased risk of stent thrombosis, particularly within the first months after stent implantation 4, 5
• If DAPT must be interrupted for surgical procedures, aspirin should be continued if possible, and P2Y12 inhibitor therapy should be restarted as soon as possible 6
• The risk of stent thrombosis is highest in the first days to weeks after stent implantation, making DAPT adherence particularly crucial during this period 1
• When treating patients with stent restenosis, consider that the underlying substrate may involve endothelial dysfunction, which further emphasizes the importance of appropriate antiplatelet therapy 4

By following these evidence-based recommendations, the risk of recurrent stent thrombosis and adverse cardiac events can be minimized while balancing the risk of bleeding complications in patients who have undergone angioplasty for stent restenosis.