Dual Antiplatelet Therapy After Carotid Endarterectomy
Single antiplatelet therapy (aspirin or clopidogrel alone) is recommended over dual antiplatelet therapy following carotid endarterectomy for most patients. 1, 2
Primary Recommendation
For patients following carotid endarterectomy, single antiplatelet therapy with either aspirin (75-100 mg daily) or clopidogrel (75 mg daily) is preferred over dual antiplatelet therapy. 1, 2
The American College of Chest Physicians explicitly recommends single over dual antiplatelet therapy (Grade 2B) for patients after carotid endarterectomy. 1
This recommendation applies to both previously symptomatic and asymptomatic patients who undergo the procedure, as the evidence for symptomatic carotid stenosis is considered applicable to all post-endarterectomy patients. 1
Evidence Supporting Single Antiplatelet Therapy
Antiplatelet therapy reduces stroke risk after carotid endarterectomy (OR 0.58; 95% CI 0.34-0.98), translating to 34 fewer strokes per 1,000 patients treated. 1
Low-dose aspirin (81-325 mg) is superior to high-dose aspirin (650-1,300 mg), with lower rates of combined stroke, MI, and death at 30 days (5.4% vs 7.0%) and 3 months (6.2% vs 8.4%). 1
Single antiplatelet therapy reduces major complications compared to dual therapy, including lower rates of 30-day death, neck hematoma, myocardial infarction, and major bleeding, without increasing stroke or TIA risk. 3
When Dual Antiplatelet Therapy May Be Considered
The only scenario where dual antiplatelet therapy is recommended after carotid intervention is following carotid artery stenting (CAS), not endarterectomy. 1
For CAS specifically, dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) is recommended for a minimum of 30 days (Class I, Level C). 1
If a patient requires dual antiplatelet therapy for another indication (such as recent coronary stenting), clopidogrel plus aspirin may be used for up to 1 year post-CEA, but this represents a special circumstance rather than standard practice. 1
Important Clinical Considerations
Timing of antiplatelet initiation: While optimal timing is not well-established, antiplatelet therapy should be initiated perioperatively and continued long-term for secondary stroke prevention. 1
Bleeding risk with dual therapy: Dual antiplatelet therapy after CEA significantly increases neck hematoma risk (OR 2.120; 95% CI 1.431-3.142) and major bleeding complications. 3
For patients on anticoagulation who undergo CEA: Antiplatelet therapy should be stopped and anticoagulation alone continued when safe from post-operative bleeding perspective (typically 3-14 days after surgery). 1
Common Pitfalls to Avoid
Do not extrapolate CAS guidelines to CEA patients: The requirement for dual antiplatelet therapy applies to carotid stenting, not endarterectomy, due to different thrombotic mechanisms. 1
Avoid high-dose aspirin: Doses above 325 mg increase bleeding complications without additional benefit. 1
Do not discontinue antiplatelet therapy prematurely: Long-term single antiplatelet therapy is essential for secondary stroke prevention and should be continued indefinitely unless contraindicated. 1, 2