What is the recommended antiplatelet therapy for patients with a previous Percutaneous Coronary Intervention (PCI)?

Antiplatelet Therapy Following Percutaneous Coronary Intervention

For patients with previous PCI, dual antiplatelet therapy (DAPT) consisting of aspirin 75-100 mg daily plus a P2Y12 inhibitor is mandatory for 12 months in acute coronary syndrome (ACS) patients, while stable coronary artery disease patients require a minimum of 6 months of DAPT. 1

Initial P2Y12 Inhibitor Selection

For ACS Patients Undergoing PCI

Ticagrelor is the first-line P2Y12 inhibitor (180 mg loading dose, then 90 mg twice daily) on top of aspirin, regardless of initial treatment strategy, including patients previously on clopidogrel (which should be discontinued when ticagrelor is started). 1, 2

Prasugrel is the alternative first-line agent (60 mg loading dose, then 10 mg daily) for P2Y12 inhibitor-naïve patients with NSTE-ACS or STEMI undergoing PCI, unless there is high bleeding risk or contraindications. 1, 2

Critical contraindication: Prasugrel is absolutely contraindicated (Class III: Harm) in patients with prior stroke or transient ischemic attack due to increased cerebrovascular bleeding risk. 1, 2 Ticagrelor should be used instead in these patients. 2

Clopidogrel is reserved for third-line use (600 mg loading dose, then 75 mg daily) only when ticagrelor or prasugrel are contraindicated, including patients with prior intracranial bleeding or those requiring oral anticoagulation. 1, 2

For Stable CAD Patients Undergoing PCI

Clopidogrel is the recommended P2Y12 inhibitor (600 mg loading dose, then 75 mg daily) for stable coronary disease patients undergoing stent implantation. 1

Aspirin Dosing

Maintain low-dose aspirin at 75-100 mg daily when used in combination with any P2Y12 inhibitor to minimize bleeding risk while preserving efficacy. 1, 2 Higher aspirin doses increase bleeding without improving ischemic outcomes. 2

Standard DAPT Duration

ACS Patients

Continue DAPT for 12 months after PCI with stent implantation, regardless of stent type (bare-metal or drug-eluting). 1, 2 This duration applies to both STEMI and NSTE-ACS patients. 1

For high bleeding risk patients (PRECISE-DAPT score ≥25), consider shortening DAPT duration to 6 months. 1 This is a Class IIa recommendation. 1

Stable CAD Patients

Continue DAPT for 6 months minimum after drug-eluting stent implantation in stable coronary disease. 1 For patients at high bleeding risk, consider shortening to 3 months (Class IIa) or even 1 month (Class IIb). 1

Bleeding Risk Mitigation Strategies

Three mandatory interventions to reduce bleeding:

• Use radial artery access over femoral access for coronary angiography and PCI when performed by an experienced radial operator. 1, 2

• Prescribe a proton pump inhibitor (PPI) in combination with DAPT for all patients to reduce gastrointestinal bleeding. 1, 2, 3 This is a Class I recommendation. 3

• Maintain aspirin at 75-100 mg daily rather than higher doses. 1, 2

Switching Between P2Y12 Inhibitors

In ACS patients previously on clopidogrel, switch to ticagrelor immediately upon hospital admission with a 180 mg loading dose, regardless of the timing or loading dose of clopidogrel. 1, 2 Do not continue clopidogrel when ticagrelor is initiated. 1

Perioperative Management

Timing of Elective Surgery

For non-emergent cardiac surgery, delay the procedure based on the P2Y12 inhibitor:

• Ticagrelor: Stop at least 3 days before surgery 1
• Clopidogrel: Stop at least 5 days before surgery 1
• Prasugrel: Stop at least 7 days before surgery 1

Continue aspirin throughout the perioperative period at a low daily dose for all patients undergoing non-emergent cardiac surgery. 1 This is a Class I recommendation. 1

Resume P2Y12 inhibitor therapy postoperatively as soon as hemostasis is secure to complete the recommended DAPT duration. 1, 3 The thrombotic risk is highest in the first month after ACS, making DAPT interruption extremely dangerous. 3

Emergent Surgery Within 1 Month of PCI

Proceed to surgery with continued DAPT when surgery cannot be delayed beyond 1 month after stent implantation. 1, 4 The consequences of stent thrombosis are far more serious than bleeding complications except in intracranial surgery. 4

For intracranial procedures only, consider stopping DAPT with bridge therapy using short-acting intravenous antiplatelet agents (cangrelor, tirofiban, or eptifibatide). 1, 4

Special Populations

Patients Requiring Oral Anticoagulation

For atrial fibrillation patients on oral anticoagulation after PCI:

• Discontinue aspirin after 1-4 weeks while maintaining P2Y12 inhibitor plus oral anticoagulant (dual therapy). 1 Earlier discontinuation of aspirin (even at discharge) is acceptable when the patient is on a P2Y12 inhibitor and therapeutic anticoagulation. 1

• Use clopidogrel as the P2Y12 inhibitor rather than ticagrelor or prasugrel due to significantly lower bleeding risk with triple therapy. 1, 2

• Continue dual therapy (P2Y12 inhibitor + anticoagulant) for 6-12 months, then transition to anticoagulation monotherapy. 1

Patients with Prior Stent Thrombosis

Continue prolonged DAPT in patients with prior stent thrombosis, especially when no correctable cause was identified. 1 These patients require extended therapy beyond standard durations. 1

Patients with Complex PCI or Peripheral Artery Disease

Consider prolonged DAPT regimen (up to 36 months) in patients who have undergone complex PCI or have lower extremity arterial disease, provided they tolerate DAPT without bleeding complications. 1

After 12 Months: Long-Term Antiplatelet Strategy

Discontinue DAPT at 12 months for most patients and continue aspirin monotherapy alone. 1

For select high ischemic risk patients (prior myocardial infarction, complex PCI, peripheral artery disease) who tolerated DAPT without bleeding, consider continuing DAPT up to 36 months. 1 This is a Class IIb recommendation. 1

Alternative strategy: Recent evidence supports P2Y12 inhibitor monotherapy (discontinuing aspirin while continuing the P2Y12 inhibitor) after completing the initial DAPT period, particularly in intermediate- to high-risk patients to reduce bleeding while maintaining ischemic protection. 5, 6

Common Pitfalls to Avoid

Do not use prasugrel in patients with prior stroke/TIA – this is a Class III: Harm recommendation due to increased fatal intracranial bleeding. 1, 2, 3

Do not administer prasugrel before coronary anatomy is known in NSTE-ACS patients, as it should only be given once the decision to proceed with PCI is established. 1

Do not discontinue DAPT prematurely in the first month after stent placement except for life-threatening bleeding that cannot be controlled. 1, 3 The thrombotic risk during this period is extreme. 3

Do not use higher aspirin doses (>100 mg daily) when combined with P2Y12 inhibitors, as this increases bleeding without improving efficacy. 1, 2

Do not forget to prescribe a PPI with DAPT – this simple intervention significantly reduces gastrointestinal bleeding. 1, 2, 3

Do not perform routine platelet function testing to adjust antiplatelet therapy before or after elective stenting, as this is not recommended. 1