What patient education is important after stent placement?

Critical Patient Education After Coronary Stent Placement

Patients must understand that stopping their antiplatelet medications prematurely—even for a few days—can cause fatal stent thrombosis, heart attack, or death, and they should never discontinue these medications without first contacting their cardiologist. 1

Dual Antiplatelet Therapy (DAPT): The Most Critical Education Point

Never Stop Medications Without Calling Your Cardiologist First

• Patients must be explicitly instructed before hospital discharge to contact their treating cardiologist before stopping any antiplatelet therapy, even if another healthcare provider (surgeon, dentist, or other physician) instructs them to stop. 1
• Abrupt discontinuation of antiplatelet therapy dramatically increases the risk of stent thrombosis, which results in death or myocardial infarction in 64.4% of cases, with mortality rates ranging from 20-45%. 1
• In one study, 6 of 7 patients who stopped their thienopyridine (clopidogrel/ticlopidine) before surgery within 90 days of stent placement died in a manner suggestive of stent thrombosis. 1

Duration of DAPT Requirements

For bare-metal stents:

• DAPT with aspirin and clopidogrel must be taken for at least 1 month. 1
• After 1 month, aspirin should be continued indefinitely at 75-162 mg daily. 1

For drug-eluting stents (DES):

• DAPT must be taken for a minimum of 12 months if the patient is not at high bleeding risk. 1
• The original recommendations were 3 months for sirolimus-eluting stents and 6 months for paclitaxel-eluting stents, but current guidelines recommend ideally up to 12 months for all DES types. 1
• After completing DAPT, aspirin should be continued indefinitely at 75-162 mg daily. 1

Medication Specifics

• Aspirin: 75-325 mg daily (lower doses of 75-162 mg preferred for long-term use due to fewer bleeding complications). 1
• Clopidogrel: 75 mg daily (most common P2Y12 inhibitor). 1
• Prasugrel: 10 mg daily (or 5 mg if body weight <60 kg) - used primarily in acute coronary syndrome patients. 2
• Patients should understand these medications work by preventing blood clots in the stent and cannot be substituted with other "blood thinners" like warfarin. 1

Surgery and Dental Procedures: Critical Timing Information

Elective Surgery Must Be Postponed

• All elective surgical procedures should be postponed until 12 months after DES implantation. 1
• For bare-metal stents, elective surgery should be delayed for at least 1 month. 1
• If surgery absolutely cannot be deferred and must occur before 12 months, aspirin should be continued during the perioperative period if at all possible, and the P2Y12 inhibitor should be restarted as soon as possible after the procedure. 1

Specific Timing for Stopping Medications Before Urgent Surgery

• If coronary artery bypass graft (CABG) surgery is needed, clopidogrel should be withheld for at least 5-7 days before surgery. 1
• Prasugrel should be discontinued at least 7 days prior to CABG if possible. 2
• The risk of CABG-related major bleeding is significantly higher if thienopyridines are taken within 3 days of surgery (26.7% with prasugrel vs 5.0% with clopidogrel), but decreases substantially if stopped 4-7 days before (11.3% vs 3.4%). 2

Dental Procedures Can Usually Proceed Safely

• Minor dental procedures (teeth cleaning, single tooth extraction) can likely be performed without stopping antiplatelet medications, as studies show no statistically significant difference in postoperative bleeding. 1
• Patients should inform their dentist about their stent and medications, but should not automatically stop medications for routine dental work. 1

Warning Signs Requiring Immediate Medical Attention

Symptoms of Stent Thrombosis or Heart Attack

• New or worsening chest pain, especially if more severe, more frequent, occurring with less exertion, or happening at rest. 3
• Chest pain not relieved by sublingual nitroglycerin (patients should be provided with nitroglycerin and clear instructions for use). 3
• Shortness of breath, sweating, nausea, or lightheadedness accompanying chest discomfort. 3
• Any symptoms similar to those experienced during the original heart attack or stent procedure. 3

Bleeding Complications

• Unusual bruising or bleeding that doesn't stop with pressure. 1
• Black or bloody stools, blood in urine, or coughing up blood. 1
• Severe headache or confusion (potential signs of intracranial bleeding). 1

Medication Adherence Barriers and Solutions

Cost and Access Issues

• The cost of clopidogrel (approximately $4 daily, though generic versions may be less expensive) has been identified as a reason patients discontinue therapy. 1
• Patients should discuss financial concerns with their healthcare team before discharge rather than simply stopping medications. 1
• Lapses in therapy should be avoided, and if medications must be temporarily discontinued due to side effects, they should be restarted as soon as possible. 2

Risk Factors for Non-Adherence

• Patients at higher risk for premature discontinuation include those who are older, have less formal education, are not married, did not receive discharge medication instructions, were not referred for cardiac rehabilitation, or avoid seeking healthcare due to cost. 1
• Additional patient education about the rationale for and importance of continuing thienopyridine treatment is especially needed for patients with less formal education. 1

Interactions with Other Healthcare Providers

Educating All Healthcare Providers

• Patients should carry a card or wear medical alert identification stating they have a coronary stent and the date of implantation. 1
• Before any medical, surgical, or dental procedure, patients must inform the provider about their stent and current medications. 1
• Healthcare providers who are concerned about bleeding during procedures must be made aware of the catastrophic risks (death, MI) of premature discontinuation and should contact the patient's cardiologist to discuss optimal management. 1

Common Pitfall to Avoid

• Many patients are routinely instructed to stop "blood thinners" before procedures without distinction between warfarin and antiplatelet agents—this is dangerous and inappropriate for stent patients. 1
• Antiplatelet medications (aspirin, clopidogrel, prasugrel) are NOT the same as anticoagulants (warfarin) and serve a different, critical function in preventing stent thrombosis. 1

Additional Lifestyle and Follow-Up Education

Continuing Other Cardiac Medications

• Patients should continue all prescribed antianginal medications (beta-blockers, nitrates, calcium channel blockers) as directed. 3
• Statins and other cardiovascular risk reduction medications should be continued indefinitely. 3

Follow-Up Care

• Telephone follow-up can reinforce hospital instructions, provide reassurance, and answer questions. 3
• Enrollment in cardiac rehabilitation programs enhances patient education and compliance with the medical regimen. 3
• Regular follow-up appointments with the cardiologist are essential to monitor for complications and adjust medications as needed. 3

Risk Factor Modification

• Smoking cessation is critical, as smoking increases the risk of stent thrombosis. 3
• Blood pressure and diabetes control should be optimized. 3
• Weight management and regular physical activity (as approved by the cardiologist) support long-term outcomes. 3