What is the recommended antiplatelet regimen for patients post Percutaneous Coronary Intervention (PCI) with a stent?

Post-PCI Antiplatelet Therapy Recommendations

All patients should receive aspirin indefinitely after PCI, combined with a P2Y12 inhibitor for a duration that depends on clinical presentation and stent type, with aspirin 81 mg daily preferred over higher doses for long-term maintenance. 1

Immediate Post-PCI Management

Aspirin Therapy

• Continue aspirin indefinitely at 81 mg daily after the initial post-procedural period 1
• Patients already on aspirin should take 81-325 mg before PCI 1
• Those not on aspirin should receive non-enteric aspirin 325 mg before PCI 1
• Lower maintenance doses (81 mg) are reasonable and preferred over higher doses to reduce bleeding risk 1

P2Y12 Inhibitor Loading

• Administer a loading dose before or at time of PCI 1:
  • Clopidogrel 600 mg (for both ACS and non-ACS patients) 1
  • Prasugrel 60 mg (ACS patients only) 1, 2
  • Ticagrelor 180 mg (ACS patients) 1

Duration of Dual Antiplatelet Therapy (DAPT)

For Acute Coronary Syndrome (ACS) Patients

DAPT should be continued for at least 12 months regardless of stent type (BMS or DES) 1. Options include:

• Clopidogrel 75 mg daily 1
• Prasugrel 10 mg daily 1, 2
• Ticagrelor 90 mg twice daily 1

The European guidelines support this 12-month duration for ACS patients with strong Class I, Level A evidence 1.

For Non-ACS (Stable) Patients

Drug-Eluting Stents (DES):

• Clopidogrel 75 mg daily for at least 12 months if not at high bleeding risk 1
• The 2024 ESC guidelines now recommend up to 6 months as the default strategy for stable patients 1
• Recent evidence supports shortening to 1-3 months in high bleeding risk patients 1, 3

Bare-Metal Stents (BMS):

• Minimum of 1 month, ideally up to 12 months 1
• If increased bleeding risk: minimum of 2 weeks 1

Special Considerations

High Bleeding Risk Patients

• Earlier discontinuation of P2Y12 inhibitor (1-3 months) is reasonable when bleeding risk outweighs ischemic benefit 1
• Continue with single antiplatelet therapy after early DAPT cessation 1
• The PRECISE-DAPT score ≥25 identifies high bleeding risk patients 1

Extended DAPT Beyond 12 Months

• May be considered in patients with DES, particularly those at high ischemic risk and low bleeding risk 1
• Ticagrelor monotherapy 90 mg twice daily may be considered as alternative to continued DAPT in high ischemic risk patients 1

P2Y12 Inhibitor Selection in ACS

Prasugrel and ticagrelor are preferred over clopidogrel in ACS patients undergoing PCI, as they provide superior reduction in cardiovascular events 1, 4:

• Prasugrel: More potent than clopidogrel but contraindicated in patients with prior stroke/TIA 2
• Ticagrelor: Reversible P2Y12 inhibitor with faster offset 1
• Clopidogrel: Use only when prasugrel or ticagrelor are unavailable or contraindicated 1

Prasugrel-Specific Warnings

• Contraindicated in patients with prior stroke or TIA 2
• Generally not recommended in patients ≥75 years (except high-risk situations with diabetes or prior MI) 2
• Consider 5 mg maintenance dose in patients <60 kg 2
• Discontinue at least 7 days before elective surgery 2

Gastrointestinal Protection

Proton Pump Inhibitors (PPIs)

• Should be used in patients with prior GI bleeding requiring DAPT 1
• Reasonable to use in patients at increased GI bleeding risk (advanced age, concurrent warfarin/steroids/NSAIDs, H. pylori infection) 1
• Not recommended routinely in low-risk patients 1

Patients Requiring Anticoagulation

Triple Therapy Management

• In patients requiring warfarin plus DAPT, target INR 2.0-2.5 with low-dose aspirin (75-81 mg) and clopidogrel 75 mg 1
• Triple therapy increases bleeding risk and requires close monitoring 1
• For patients on oral anticoagulation (OAC) after PCI, DOACs are preferred over warfarin 1
• Early aspirin cessation (≤1 week) followed by OAC plus clopidogrel for 6-12 months, then OAC alone 1

Critical Counseling Points

Patients must be counseled on:

• The critical importance of DAPT compliance 1
• Never discontinue therapy without discussing with their cardiologist 1
• Risks and benefits before stent placement, especially DES 1
• Premature discontinuation, particularly in first weeks after ACS, significantly increases risk of cardiovascular events 2

Common Pitfalls to Avoid

• Do not routinely perform genetic or platelet function testing to guide therapy—this is not recommended 1
• Do not use prasugrel in patients with prior stroke/TIA—this is an absolute contraindication 2
• Do not delay urgent surgery for 12 months after stenting—the mandatory interval has been shortened to 6 months (3 months if surgery cannot be delayed) for modern DES 5
• Do not continue high-dose aspirin long-term—switch to 81 mg daily after initial period 1