What is the recommended duration of Dual Antiplatelet Therapy (DAPT) for a patient with a stent in the ramus?

Duration of Dual Antiplatelet Therapy for Megatron 4 x 27 Stent in the Ramus

For a patient with a Megatron 4 x 27 stent in the ramus, dual antiplatelet therapy (DAPT) should be administered for at least 12 months if the stent was placed in the setting of acute coronary syndrome (ACS). 1

Recommended DAPT Duration Based on Clinical Scenario

For ACS Patients (NSTEMI or STEMI):

• DAPT with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months after drug-eluting stent (DES) implantation 1
• Daily aspirin dose should be 81 mg (range 75-100 mg) 1
• In ACS patients who are not at high bleeding risk and without history of stroke/TIA, ticagrelor or prasugrel is preferred over clopidogrel for maintenance P2Y12 inhibitor therapy 1
• If the patient develops high bleeding risk (e.g., requiring oral anticoagulation) or experiences significant bleeding, discontinuation of P2Y12 inhibitor after 6 months may be reasonable 1

For Stable Ischemic Heart Disease (SIHD):

• The minimum recommended duration of DAPT after DES implantation is 6 months 1
• For patients at high bleeding risk, shorter DAPT duration (3 months) may be considered 1

Considerations for Extended DAPT Beyond 12 Months

• For ACS patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation of DAPT beyond 12 months may be reasonable 1
• Extended DAPT reduces stent thrombosis (OR: 0.45; 95% CI: 0.24 to 0.74) and myocardial infarction (OR: 0.67; 95% CI: 0.47 to 0.95) but increases major bleeding (OR: 1.58; 95% CI: 1.20 to 2.09) 1
• Risk-benefit analysis shows 3 fewer stent thromboses and 6 fewer MIs but 5 more major bleeds per 1000 patients treated with prolonged DAPT per year 1

P2Y12 Inhibitor Selection

• For ACS patients, ticagrelor is reasonable to use in preference to clopidogrel (Class IIa recommendation) 1
• Prasugrel may be chosen over clopidogrel in ACS patients without history of stroke/TIA and not at high bleeding risk (Class IIa recommendation) 1
• Prasugrel should not be administered to patients with prior history of stroke or TIA (Class III: Harm) 1

Special Considerations

• For patients at high bleeding risk or those requiring oral anticoagulation, a shorter DAPT duration (6 months) may be considered 1
• The risk of stent thrombosis is greatest in the first days to weeks after implantation, particularly with bare metal stents 1
• Newer-generation DES have lower risk of stent thrombosis compared to first-generation DES and may require shorter minimum duration of DAPT 1

Practical Algorithm for DAPT Duration Decision

1. Determine if stent was placed for ACS or stable CAD:

   • For ACS → 12 months of DAPT is standard 1
   • For stable CAD → 6 months of DAPT is standard 1

2. Assess bleeding risk:

   • If high bleeding risk → Consider shorter duration (6 months for ACS, 3 months for stable CAD) 1
   • If low bleeding risk → Consider standard or extended duration 1

3. Consider stent complexity:

   • Complex PCI (which may include ramus interventions) may benefit from longer DAPT duration 1

4. Evaluate ischemic risk:

   • Prior MI, diabetes, or multiple stents may benefit from extended DAPT 2

Remember that the decision to extend DAPT beyond 12 months should carefully weigh the reduced risk of stent thrombosis and MI against the increased risk of bleeding 1.