From the Guidelines
For patients with drug-eluting stents (DES), dual antiplatelet therapy (DAPT) consisting of aspirin 81mg daily indefinitely plus a P2Y12 inhibitor is recommended, with the P2Y12 inhibitor continued for at least 12 months after DES placement, as supported by the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease 1.
Key Considerations
- The recommended daily dose of aspirin in patients treated with DAPT is 81 mg (range, 75 mg to 100 mg) 1.
- For patients at high bleeding risk, a shorter DAPT duration of 3-6 months may be considered, while those at high ischemic risk and low bleeding risk may benefit from extended DAPT beyond 12 months 1.
- The newer generation DES have lower thrombotic risk than earlier versions, allowing for potentially shorter DAPT durations in selected patients 1.
Anticoagulation Therapy
- For patients requiring anticoagulation (such as those with atrial fibrillation), triple therapy (DAPT plus anticoagulant) should be kept as short as possible (typically 1-6 months) before transitioning to dual therapy (single antiplatelet plus anticoagulant) 1.
P2Y12 Inhibitor Selection
- The P2Y12 inhibitor (typically clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) should be chosen based on patient-specific factors, including bleeding risk and ischemic risk 1.
Aspirin Therapy
- Aspirin therapy should almost always be continued indefinitely in patients with CAD, as it provides long-term ischemic protection 1.
From the Research
DES Stent Anticoagulant Guideline
The following information is based on studies regarding the duration and type of anticoagulant therapy after DES stent implantation:
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is commonly used to reduce thrombotic events after percutaneous coronary intervention (PCI) with DES 2.
- The optimal duration of DAPT after DES implantation is still debated, with some studies suggesting that a shorter course of DAPT may be sufficient, especially with second-generation or newer-generation DES 3, 4.
- A systematic review and network meta-analysis found that long-term DAPT resulted in higher rates of major bleeding and non-cardiac death, while standard-term DAPT was associated with higher rates of any bleeding 4.
- Another study found that short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy was associated with lower major bleeding and similar stent thrombosis, all-cause death, myocardial infarction, and stroke compared to prolonged DAPT 5.
- A review of efficacy and safety studies found that the combination of clopidogrel and low-dose aspirin for 12 months is the preferred regimen for the prevention of stent thrombosis and cardiac complications after DES placement 6.
Key Findings
- Short-term DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy may be a viable alternative to prolonged DAPT 5.
- The type of P2Y12 inhibitor used may not significantly impact the outcomes, but further investigation is needed 5.
- Triple antiplatelet therapy may be beneficial in certain high-risk patients, but it is not associated with an increased risk of major or minor bleeding events compared to dual therapy 6.
- The combination of prasugrel and aspirin may be appropriate in patients with acute coronary syndrome (ACS), but it is associated with a significantly increased risk for bleeding 6.