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

Antiplatelet Therapy Post-PCI

For patients without atrial fibrillation, initiate dual antiplatelet therapy (DAPT) with aspirin 75-100 mg daily plus a P2Y12 inhibitor for 12 months after acute coronary syndrome (ACS) or 6 months after stable coronary artery disease (CAD), then continue aspirin monotherapy indefinitely. 1, 2

Initial P2Y12 Inhibitor Selection

For ACS patients undergoing PCI:

• Ticagrelor is the preferred first-line agent with a 180 mg loading dose followed by 90 mg twice daily 1
• Prasugrel is an alternative first-line option with a 60 mg loading dose followed by 10 mg daily, unless contraindicated 1, 3
• Clopidogrel 75 mg daily is reserved for patients with high bleeding risk or those requiring oral anticoagulation 1, 2

Critical prasugrel contraindications and warnings:

• Absolutely contraindicated in patients with prior stroke or TIA (6.5% stroke rate vs 1.2% with clopidogrel) 3
• Generally not recommended in patients ≥75 years due to increased fatal and intracranial bleeding risk, except in high-risk situations (diabetes or prior MI) 3
• Consider dose reduction to 5 mg daily in patients <60 kg due to increased bleeding risk, though this dose lacks prospective validation 3
• Discontinue at least 7 days before elective surgery 3

Aspirin Dosing Strategy

• Maintain low-dose aspirin at 75-100 mg daily when combined with any P2Y12 inhibitor to minimize bleeding while preserving efficacy 1, 2
• For patients not on aspirin pre-PCI, give non-enteric aspirin 325 mg before the procedure 2
• Continue aspirin indefinitely after DAPT completion 1, 2

Standard DAPT Duration

For ACS patients:

• Continue DAPT for 12 months regardless of stent type 1, 2

For stable CAD patients:

• Continue DAPT for minimum 6 months after drug-eluting stent implantation 1, 2

Individualized duration adjustments:

• Discontinue P2Y12 inhibitor at 6 months in patients with high bleeding risk or low ischemic risk 4
• Consider extending DAPT beyond 12 months (up to 36 months) in select high ischemic risk patients who tolerated DAPT without bleeding 1

Recent evidence suggests that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces net adverse clinical events and major bleeding without increasing ischemic events 5. This strategy may be considered in appropriate patients, though it represents a departure from traditional guidelines.

Bleeding Risk Mitigation

Mandatory interventions:

• Prescribe a proton pump inhibitor (PPI) for all patients on DAPT to reduce gastrointestinal bleeding (Class I recommendation) 1
• Use radial artery access over femoral access for PCI to reduce bleeding risk 1, 4

High-risk bleeding populations requiring special consideration:

• Patients <60 kg body weight 3
• Patients ≥75 years of age 3
• History of prior bleeding 6
• Concomitant use of anticoagulants or NSAIDs 3

Special Population: Atrial Fibrillation Requiring Anticoagulation

This population requires a fundamentally different approach:

Peri-PCI phase:

• Administer aspirin plus clopidogrel (preferred P2Y12 inhibitor) during immediate peri-PCI phase through hospital discharge 6, 4
• Avoid prasugrel and consider ticagrelor only in high ischemic/low bleeding risk patients 6

Post-discharge strategy:

• Discontinue aspirin at hospital discharge or within 1 week and transition to double therapy (oral anticoagulant + clopidogrel 75 mg daily) 6, 4
• Prefer a DOAC over warfarin at established stroke prevention doses 6, 4
• Only extend aspirin (81 mg daily) for up to 1 month in highly selected patients with high ischemic/thrombotic risk and low bleeding risk 6, 4

Duration of P2Y12 inhibitor with anticoagulation:

• Discontinue at 6 months in high bleeding risk or low ischemic risk patients 6, 4
• Continue for 12 months in standard risk patients 4
• May extend beyond 12 months in high ischemic/low bleeding risk patients 4

After P2Y12 inhibitor discontinuation:

• Continue oral anticoagulation monotherapy at full stroke-prevention doses indefinitely 4
• If using rivaroxaban at the reduced dose tested in PIONEER-AF PCI (15 mg daily), increase to full FDA-approved dose (20 mg daily) once antiplatelet therapy stops 6, 4

Warfarin-specific considerations:

• Maintain INR at the lower end of therapeutic range (2.0-2.5) 6
• Consider bridging with parenteral anticoagulation only in high thromboembolic risk patients until INR reaches therapeutic range 6, 4
• In patients not bridged, consider continuing low-dose aspirin with P2Y12 inhibitor until INR is therapeutic, then stop aspirin 6

Perioperative Management

For non-emergent cardiac surgery:

• Stop ticagrelor at least 3 days before surgery 1
• Stop clopidogrel at least 5 days before surgery 1
• Stop prasugrel at least 7 days before surgery 1, 3
• Continue aspirin throughout the perioperative period at low daily dose (Class I recommendation) 1

Timing of Anticoagulation Resumption Post-PCI

For patients on chronic anticoagulation:

• Resume oral anticoagulation within 24 hours post-PCI in most patients after assessing hemostasis at the access site 6, 4
• In select patients, this could be as early as the evening of the PCI day, depending on operator and institutional preferences 6
• For patients unable to take oral medications, consider parenteral anticoagulation (unfractionated heparin or LMWH) within 24 hours (low bleeding risk) or 48-72 hours (high bleeding risk) 6

Common Pitfalls to Avoid

• Never use prasugrel in patients with prior stroke/TIA - this is an absolute contraindication with documented harm 3
• Do not routinely use triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) beyond 1 month - double therapy is the default strategy 6, 4
• Avoid premature discontinuation of P2Y12 inhibitors - this significantly increases risk of stent thrombosis, MI, and death 3
• Do not use standard prasugrel dosing (10 mg) in patients <60 kg without considering dose reduction to 5 mg 3
• Do not forget PPI prophylaxis - this is a Class I recommendation for all patients on DAPT 1