What is the recommended long-term antiplatelet regimen for patients post Percutaneous Coronary Intervention (PCI) stenting?

Long-Term Antiplatelet Regimen Post-PCI Stenting

For stable coronary artery disease (SCAD), continue dual antiplatelet therapy (DAPT) for 6 months, then switch to aspirin 75-100 mg daily lifelong; for acute coronary syndrome (ACS), continue DAPT for 12 months, then switch to aspirin 75-100 mg daily lifelong. 1

Standard DAPT Regimens by Clinical Presentation

Stable Coronary Artery Disease (Elective PCI)

• Default duration: DAPT with aspirin 75-100 mg plus clopidogrel 75 mg daily for 6 months after drug-eluting stent placement 1
• After 6 months: Transition to aspirin 75-100 mg daily lifelong as single antiplatelet therapy 1
• Alternative to aspirin: Clopidogrel 75 mg daily is equally safe and effective for long-term monotherapy 1

Acute Coronary Syndrome (ACS Post-PCI)

• Default duration: DAPT for at least 12 months regardless of stent type 1
• Preferred P2Y12 inhibitors (in order of preference):
  • Ticagrelor 90 mg twice daily (180 mg loading dose) 1
  • Prasugrel 10 mg daily (60 mg loading dose) in P2Y12-naïve patients without prior stroke/TIA 1
  • Clopidogrel 75 mg daily (600 mg loading dose) only when ticagrelor or prasugrel contraindicated 1
• After 12 months: Transition to aspirin 75-100 mg daily lifelong 1

Modifying DAPT Duration Based on Risk

Shortened DAPT (High Bleeding Risk)

• 3 months DAPT: Should be considered in patients with high bleeding risk (e.g., PRECISE-DAPT score ≥25) 1
• 1 month DAPT: May be considered in patients with very high bleeding risk or life-threatening bleeding concerns 1
• After shortened DAPT, continue with single antiplatelet therapy (aspirin or clopidogrel) 1

Extended DAPT (High Ischemic Risk)

• Beyond 12 months in ACS: May be reasonable in patients who tolerated DAPT without bleeding complications and are not at high bleeding risk 1
• Beyond 6 months in SCAD: May be considered (up to 30 months) in patients at low bleeding risk but high thrombotic risk (e.g., complex left main PCI, prior stent thrombosis, complex bifurcation stenting) 1
• Reduced-dose ticagrelor: Consider ticagrelor 60 mg twice daily (instead of 90 mg) for extended therapy beyond 12 months in post-MI patients 2

Special Populations and Considerations

Patients Requiring Oral Anticoagulation

• Triple therapy duration: Limit to maximum 6 months or discontinue aspirin at hospital discharge, continuing only oral anticoagulation plus clopidogrel 1
• After uncomplicated PCI: Discontinue aspirin within 1 week, continue oral anticoagulation plus clopidogrel for 6-12 months depending on ischemic risk 1, 3
• Preferred anticoagulant: Direct oral anticoagulants (DOACs) over warfarin 1, 3
• Do not use: Ticagrelor or prasugrel in combination with oral anticoagulation 1

High-Risk Anatomical/Procedural Features

• Consider prasugrel or ticagrelor (instead of clopidogrel) for first 1-3 months in complex left main stenting, 2-stent bifurcation, suboptimal stenting result, or prior stent thrombosis 1
• May warrant extended DAPT duration beyond standard recommendations 1

Patients Requiring Surgery

• Elective surgery: Should be delayed until at least 1 month after stent placement if aspirin can be maintained perioperatively 1
• If both agents must be stopped: Consider bridging with cangrelor, tirofiban, or eptifibatide, especially within 1 month of stent placement 1
• Prasugrel-specific: Discontinue at least 7 days before CABG 4

Emerging Evidence: Abbreviated DAPT with P2Y12 Monotherapy

Recent high-quality evidence suggests an alternative strategy:

• 1-3 months DAPT followed by P2Y12 inhibitor monotherapy (particularly ticagrelor) reduces bleeding and net adverse clinical events without increasing ischemic complications 5, 6
• This strategy showed particular benefit in ACS patients and those at high bleeding risk 5, 6
• However, this approach is not yet universally adopted in guidelines and represents an evolving area of practice 7, 8

Critical Pitfalls to Avoid

• Never discontinue DAPT prematurely without compelling reason—this dramatically increases risk of stent thrombosis, MI, and death 4
• Do not use prasugrel in patients with prior stroke or TIA (absolute contraindication) 1, 4
• Avoid triple therapy (aspirin + P2Y12 inhibitor + oral anticoagulation) beyond 6 months due to excessive bleeding risk 1
• Reassess bleeding risk if patient develops active bleeding—only discontinue both agents if bleeding is life-threatening and source cannot be controlled 1
• Body weight <60 kg: Consider reduced prasugrel maintenance dose (5 mg daily instead of 10 mg) 4