What is the recommended antiplatelet therapy for a patient with coronary artery disease (CAD) status post (s/p) stent placement?

Antiplatelet Therapy for CAD Status Post Stent Placement

For a patient with coronary artery disease status post stent placement, dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is mandatory, with the specific regimen and duration determined by whether the stent was placed for acute coronary syndrome (ACS) versus stable CAD, and by the patient's bleeding risk.

Initial Regimen Selection

For ACS Patients (STEMI, NSTEMI, Unstable Angina)

Ticagrelor is the preferred P2Y12 inhibitor for all ACS patients regardless of stent type. 1, 2

• Loading dose: Ticagrelor 180 mg plus aspirin 160-325 mg 2, 3
• Maintenance: Ticagrelor 90 mg twice daily plus aspirin 75-100 mg daily 1, 2
• Alternative for PCI patients: Prasugrel 60 mg loading dose, then 10 mg daily (only if no prior stroke/TIA and undergoing PCI) 1, 2
• If ticagrelor/prasugrel contraindicated: Clopidogrel 600 mg loading dose, then 75 mg daily 2

Critical contraindication: Prasugrel must never be used in patients with prior stroke or TIA due to increased cerebrovascular bleeding risk 1, 4

For Stable CAD Patients (Elective PCI)

• Regimen: Aspirin 75-100 mg daily plus clopidogrel 75 mg daily 1
• Ticagrelor and prasugrel are not first-line for stable CAD 1

Duration of DAPT

ACS Patients: 12 Months Standard Duration

All ACS patients require 12 months of DAPT regardless of stent type (bare-metal or drug-eluting), revascularization strategy (PCI, CABG, or medical therapy alone), or completeness of revascularization. 1, 2, 5

• High bleeding risk exception: May shorten to 6 months if PRECISE-DAPT score ≥25 or other high bleeding risk features 1, 2, 5
• Extension beyond 12 months: May consider if patient tolerated DAPT without bleeding complications and ischemic risk outweighs bleeding risk 1, 5

Stable CAD Patients: 1-6 Months Duration

Duration depends on bleeding risk, not stent type. 1

• Standard duration: 6 months for most patients with newer-generation drug-eluting stents 1
• High bleeding risk: May shorten to 1-3 months 1, 6
• Bare-metal stents: Minimum 1 month, ideally up to 12 months unless high bleeding risk 1

Key principle: The need for short DAPT should no longer justify using bare-metal stents instead of newer-generation drug-eluting stents 1

Mandatory Bleeding Risk Mitigation

Every patient on DAPT must receive a proton pump inhibitor (PPI) to reduce gastrointestinal bleeding risk. 2, 5, 3

• Maintain aspirin dose at 75-100 mg daily during maintenance phase (after loading) 1, 2
• Use radial artery access (not femoral) for PCI procedures when performed by experienced radial operators 2, 3

Special Situations

Patients Requiring Oral Anticoagulation

Triple therapy (DAPT plus anticoagulation) increases bleeding risk 2-3 fold and should be limited to maximum 6 months or omitted after hospital discharge. 1, 5

• Use clopidogrel (not ticagrelor or prasugrel) as the P2Y12 inhibitor 1, 2
• Consider discontinuing aspirin 1-4 weeks after PCI, continuing only P2Y12 inhibitor plus anticoagulation 2

Planned Surgery After Stent Placement

Wait at least 1 month after stent implantation before elective surgery requiring P2Y12 inhibitor discontinuation, regardless of stent type, if aspirin can be maintained perioperatively. 1, 5

• If surgery must occur within 1 month, consider bridging with cangrelor, tirofiban, or eptifibatide 1
• For CABG in ACS patients, resume P2Y12 inhibitor after surgery to complete 12 months total DAPT 1, 5

Prior Stent Thrombosis

Patients with prior stent thrombosis, especially without correctable causes, require prolonged DAPT beyond standard durations. 1, 5

Complex PCI Features

Consider prolonged DAPT for complex PCI including left main disease, bifurcation lesions requiring two stents, total stent length >60 mm, or multiple lesions treated. 1, 5

Critical Pitfalls to Avoid

• Never use clopidogrel as first-line therapy in ACS patients when ticagrelor is available and not contraindicated - this represents suboptimal care 2
• Never discontinue DAPT prematurely, especially within the first month after stent placement - dramatically increases thrombotic risk 1, 2, 5
• Never omit PPI co-prescription - simple intervention that significantly reduces gastrointestinal bleeding 2, 5
• Never use prasugrel in patients with prior stroke/TIA - contraindicated due to increased intracranial bleeding 1, 2, 4
• Never stop both antiplatelet agents shortly after PCI unless life-threatening bleeding where source cannot be treated - if this rare scenario occurs, transfer patient to primary PCI facility 1, 5

Maintenance Phase Considerations

After completing the initial DAPT period:

• ACS patients who tolerated ticagrelor-based DAPT: Consider transitioning to ticagrelor monotherapy (discontinue aspirin) ≥1 month after PCI as bleeding reduction strategy 2, 3
• All other patients: Transition to aspirin monotherapy indefinitely 1