Can a patient stop taking Aspirin (Acetylsalicylic Acid) 81mg if they are on Plavix (Clopidogrel) and have had a Myocardial Infarction (MI) and a Transient Ischemic Attack (TIA)?

Dual Antiplatelet Therapy Should Be Continued After MI and TIA

No, a patient should NOT stop aspirin 81mg if they are on clopidogrel after having both an MI and a TIA—dual antiplatelet therapy (DAPT) with both aspirin and clopidogrel should be continued for at least 12 months post-MI, and aspirin should be continued indefinitely thereafter. 1

Rationale for Continuing Both Agents

Post-MI Requirements Take Priority

• After MI, dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel) is mandated for at least 12 months, regardless of whether a bare-metal stent or drug-eluting stent was placed. 1
• Aspirin should be continued indefinitely after MI at a maintenance dose of 81mg daily to minimize bleeding risk while maintaining cardiovascular protection. 1
• Withdrawal or discontinuation of aspirin or clopidogrel has been directly associated with recurrent acute coronary syndrome episodes, including stent thrombosis. 1

The TIA Component Does Not Change This Recommendation

• For noncardioembolic TIA alone, either clopidogrel monotherapy OR aspirin monotherapy would be acceptable options for secondary stroke prevention. 2
• However, the post-MI indication for DAPT supersedes the TIA antiplatelet requirements—the patient needs both agents for the cardiac indication. 1
• The combination of aspirin plus clopidogrel provides adequate stroke prevention while addressing the more immediate thrombotic risk from the MI. 2, 3

Duration of Therapy Algorithm

First 12 Months Post-MI

• Continue aspirin 81mg daily PLUS clopidogrel 75mg daily for the full 12-month period. 1
• This applies whether the patient received a stent or was managed medically. 1

After 12 Months Post-MI

• Continue aspirin 81mg daily indefinitely for both MI and TIA secondary prevention. 1
• Discontinue clopidogrel after the 12-month DAPT period is complete, unless there are other compelling indications. 1
• Aspirin monotherapy provides adequate long-term protection for both conditions after the high-risk post-MI period. 1, 4

Critical Safety Considerations

Bleeding Risk Assessment

• The combination of aspirin and clopidogrel does increase bleeding risk compared to monotherapy, but this risk is outweighed by the cardiovascular benefits in the first 12 months post-MI. 1, 5
• Major hemorrhagic events should be monitored, but do not routinely warrant stopping therapy unless life-threatening bleeding occurs. 3, 5

Common Pitfall to Avoid

• Never discontinue aspirin while continuing clopidogrel in a post-MI patient—this is the opposite of guideline recommendations and removes the foundational antiplatelet agent. 1
• The protective effect of aspirin has been sustained for years in clinical trials and should be continued indefinitely unless contraindications develop. 1

Special Circumstance: Prasugrel Contraindication

• Note that if the patient were on prasugrel instead of clopidogrel, this would be contraindicated given the history of TIA (prasugrel is harmful in patients with prior TIA/stroke). 1
• Clopidogrel is the appropriate P2Y12 inhibitor choice for this patient with both MI and TIA history. 1

When Aspirin Can Eventually Be Stopped

The only scenario where aspirin could be discontinued would be:

• After 12 months post-MI have elapsed AND
• A separate indication for anticoagulation develops (such as atrial fibrillation requiring therapeutic anticoagulation) AND
• The bleeding risk with triple therapy (aspirin + clopidogrel + anticoagulant) is deemed excessive. 1, 6

In such cases, the anticoagulant would provide stroke prevention for the TIA, but this is a complex decision requiring careful risk-benefit analysis. 6, 7