What medications are required for patients with stents, specifically dual antiplatelet therapy (DAPT) regimens?

Medications Required for Stents

All patients with coronary stents require dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor, with the specific regimen and duration determined by clinical presentation (acute coronary syndrome vs stable disease) and bleeding risk.

Core DAPT Components

Aspirin

• Low-dose aspirin 75-100 mg (or 81 mg) daily is mandatory for all patients with stents 1, 2
• This dose should be maintained throughout the DAPT period and continued indefinitely as monotherapy after P2Y12 inhibitor discontinuation 1
• Higher doses (>100 mg) increase bleeding risk without additional benefit 1

P2Y12 Inhibitor Selection

For Acute Coronary Syndrome (ACS) patients:

• First-line: Ticagrelor 180 mg loading dose, then 90 mg twice daily 1, 2

  • Preferred over clopidogrel regardless of stent type or revascularization strategy 1, 2
  • Can be used in patients with prior stroke/TIA 2

• Alternative: Prasugrel 60 mg loading dose, then 10 mg once daily 1, 3

  • For P2Y12 inhibitor-naïve patients undergoing PCI 1
  • Contraindicated in patients with prior stroke or TIA 1
  • Use caution in patients ≥75 years or <60 kg due to bleeding risk 2

• Third-line: Clopidogrel 600 mg loading dose, then 75 mg once daily 1

  • Reserved for patients who cannot tolerate ticagrelor or prasugrel 1, 2
  • Preferred when triple therapy (DAPT + anticoagulation) is required 1, 2

For Stable Coronary Disease patients:

• Clopidogrel 600 mg loading dose, then 75 mg once daily 1, 4
• Ticagrelor and prasugrel are not first-line for stable disease 1

Duration of DAPT

ACS Patients (STEMI, NSTEMI, Unstable Angina)

• Minimum 12 months of DAPT regardless of stent type or revascularization strategy 1, 2
• Shorten to 6 months only if high bleeding risk develops (e.g., requiring oral anticoagulation, major surgery planned, significant bleeding) 1
• Consider extending beyond 12 months if patient tolerates DAPT without bleeding complications 1

Stable CAD Patients with Stents

• Drug-eluting stents (DES): 6-12 months of DAPT 1, 5
  • Newer-generation DES may require shorter minimum duration (3-6 months) 1
• Bare-metal stents (BMS): Minimum 1 month of DAPT 1
• After completing DAPT, transition to aspirin monotherapy indefinitely 1

Bleeding Risk Mitigation Strategies

Mandatory measures to reduce bleeding complications:

• Prescribe proton pump inhibitor (PPI) with all DAPT regimens 1, 2
  • Especially critical in patients with history of GI bleeding 1
• Use radial (not femoral) arterial access for PCI procedures 1, 2
• Maintain aspirin at 75-100 mg daily (not higher doses) 1

Special Populations

Patients Requiring Oral Anticoagulation (Triple Therapy)

• Limit triple therapy duration to maximum 6 months (or discontinue after hospital discharge in selected cases) 1
• Use clopidogrel (not ticagrelor or prasugrel) as the P2Y12 inhibitor 1, 2
• Target INR 2.0-2.5 when warfarin is used 1
• Consider discontinuing aspirin 1-4 weeks after PCI and continuing P2Y12 inhibitor plus anticoagulant 2

Patients Requiring Non-Cardiac Surgery

• Do not discontinue DAPT within first month after stent placement for elective surgery 1, 4
• After 1 month, surgery may proceed with aspirin continuation and P2Y12 inhibitor held for appropriate washout period 1, 6:
  • Clopidogrel: 5-7 days 6
  • Prasugrel: 7-10 days 6
  • Ticagrelor: 3-5 days 6
• For urgent surgery within 1 month, proceed with continued DAPT unless bleeding risk is life-threatening 1, 6

Switching Between P2Y12 Inhibitors

• In ACS patients on clopidogrel, switch to ticagrelor with 180 mg loading dose regardless of clopidogrel timing or dose 2, 4
• Discontinue clopidogrel when ticagrelor is started 1, 2

Critical Pitfalls to Avoid

• Never use prasugrel in patients with prior stroke/TIA (Class III: Harm recommendation) 1, 2
• Never discontinue DAPT prematurely, especially within first month after stenting - risk of catastrophic stent thrombosis 1, 2, 4
• Never omit PPI co-prescription with DAPT - simple intervention that significantly reduces GI bleeding 1, 2
• Never use clopidogrel as first-line in ACS when ticagrelor or prasugrel are available and not contraindicated - represents suboptimal care 1, 2
• Never use ticagrelor or prasugrel in triple therapy regimens - excessive bleeding risk 1, 2