Warfarin and Dual Antiplatelet Therapy After PCI
For patients requiring warfarin after PCI, immediately transition to double therapy (oral anticoagulant plus P2Y12 inhibitor, preferably clopidogrel) at hospital discharge, discontinuing aspirin within 1-4 weeks in most patients. 1
Preferred Anticoagulation Strategy
Switch from warfarin to a DOAC (direct oral anticoagulant) post-PCI whenever possible, as DOACs demonstrate consistent bleeding reduction compared to warfarin without compromising efficacy. 1 If warfarin must be continued, maintain INR at the lower therapeutic range (2.0-2.5) to minimize bleeding risk. 1
Peri-PCI Period (During Hospitalization)
- Administer aspirin plus P2Y12 inhibitor (clopidogrel preferred) during the immediate peri-PCI phase through hospital discharge. 1, 2
- Clopidogrel remains the P2Y12 inhibitor of choice over prasugrel or ticagrelor when combined with oral anticoagulation due to lower bleeding risk. 1
- Resume oral anticoagulation within 24 hours post-PCI in most patients after assessing hemostasis at the access site. 1
Post-Discharge Antithrombotic Regimen
Default Strategy: Double Therapy
Discontinue aspirin at hospital discharge or within 1 week and continue double therapy (oral anticoagulant + clopidogrel 75 mg daily). 1, 2 This represents the evidence-based default approach for most patients.
Triple Therapy Exception
Extend aspirin (81 mg daily) for up to 1 month only in highly selected patients with ALL of the following characteristics: 1, 2
- High ischemic/thrombotic risk (complex PCI, extensive coronary disease, prior stent thrombosis)
- Low bleeding risk (no prior bleeding, age <75, normal renal function)
- Acceptable bleeding risk tolerance
Never extend triple therapy beyond 1 month. 1
Duration of P2Y12 Inhibitor Therapy
The duration depends on bleeding and ischemic risk stratification:
- High bleeding risk or low ischemic risk: Discontinue P2Y12 inhibitor at 6 months post-PCI. 1
- Standard risk patients: Continue P2Y12 inhibitor for 12 months. 1, 2
- High ischemic risk with low bleeding risk: May reasonably continue P2Y12 inhibitor beyond 12 months. 1
After P2Y12 Inhibitor Discontinuation
Continue oral anticoagulation monotherapy at full stroke-prevention doses indefinitely. 1 If using rivaroxaban at the reduced dose tested in trials (15 mg or 10 mg daily with renal adjustment), increase to the full FDA-approved dose (20 mg or 15 mg daily) once antiplatelet therapy stops. 1
Critical Warfarin-Specific Considerations
For patients remaining on warfarin post-PCI:
- Consider bridging with parenteral anticoagulation only in high thromboembolic risk patients until INR reaches therapeutic range. 1
- In non-bridged patients, continue low-dose aspirin with P2Y12 inhibitor until INR is therapeutic (≥2.0), then discontinue aspirin. 1
- Monitor INR closely as the combination of warfarin with antiplatelet agents substantially increases bleeding risk. 1
Bleeding Risk Mitigation
Add a proton pump inhibitor in all patients receiving combined anticoagulation and antiplatelet therapy to reduce gastrointestinal bleeding risk. 1 Use radial access for PCI when feasible to minimize vascular complications. 1
Common Pitfalls to Avoid
- Do not continue triple therapy beyond 1 month except in extraordinary circumstances—bleeding risk escalates dramatically with prolonged triple therapy. 1, 2
- Do not use prasugrel or ticagrelor in combination with oral anticoagulation due to excessive bleeding risk; clopidogrel is the only appropriate P2Y12 inhibitor. 1
- Do not maintain reduced-dose DOAC regimens after stopping antiplatelet therapy—uptitrate to full stroke-prevention doses. 1
- Do not default to aspirin monotherapy after stopping the P2Y12 inhibitor in anticoagulated patients—continue oral anticoagulation alone. 1, 2