What are the stent options that require antiplatelet therapy, their duration, common side effects, and subsequent treatment after discontinuation?

Coronary Stent Options and Antiplatelet Therapy Requirements

Stent Types and DAPT Duration

Both bare-metal stents (BMS) and drug-eluting stents (DES) require dual antiplatelet therapy (DAPT), but DES require longer treatment duration to prevent stent thrombosis while BMS have shorter mandatory periods.

Bare-Metal Stents (BMS)

For Acute Coronary Syndrome (ACS):

• Minimum 12 months DAPT required regardless of stent type 1
• Aspirin 75-100 mg daily plus P2Y12 inhibitor (clopidogrel 75 mg, prasugrel 10 mg, or ticagrelor 90 mg twice daily) 1, 2

For Stable Coronary Disease (Non-ACS):

• Minimum 1 month DAPT required 1
• Ideally extend to 12 months unless high bleeding risk 1
• If high bleeding risk: minimum 2 weeks acceptable 1

Drug-Eluting Stents (DES)

For Acute Coronary Syndrome:

• Minimum 12 months DAPT required 1, 2
• Consider extending beyond 12 months if patient tolerates DAPT without bleeding 1, 2

For Stable Coronary Disease:

• Minimum 6 months DAPT required 1
• Specific DES types vary: 3 months for -limus stents, 6 months for -taxel stents 1
• May shorten to 3 months if high bleeding risk outweighs benefit 1
• May shorten to 1 month in extreme bleeding risk 1

P2Y12 Inhibitor Options and Selection

For ACS Patients (First-Line to Third-Line)

First-Line: Ticagrelor

• Loading: 180 mg, then 90 mg twice daily 2
• Preferred over clopidogrel regardless of stent type 2
• Contraindicated in triple therapy regimens (excessive bleeding risk) 2

Second-Line: Prasugrel

• Loading: 60 mg, then 10 mg once daily 1, 2
• For P2Y12 inhibitor-naïve patients undergoing PCI 2
• Absolute contraindication: prior stroke or TIA 2
• Contraindicated in triple therapy regimens 2

Third-Line: Clopidogrel

• Loading: 600 mg, then 75 mg once daily 2
• Reserved for patients intolerant to ticagrelor/prasugrel 2
• Preferred when triple therapy required (DAPT + anticoagulation) 2

For Stable CAD Patients

First-Line: Clopidogrel

• Loading: 600 mg, then 75 mg once daily 1, 2
• Standard choice for elective PCI 1

Aspirin Component

Dosing Throughout DAPT:

• 75-100 mg daily preferred over higher doses 1, 2
• Higher doses (>100 mg) increase bleeding without additional benefit 2
• Continue indefinitely after P2Y12 inhibitor stopped 1

Common Side Effects

Bleeding Complications

DAPT-Related Bleeding:

• Extended DAPT (18-36 months) causes absolute 1% increase in bleeding compared to standard duration 1
• Major bleeding increases with longer duration: OR 1.58 for 18-48 months vs 6-12 months 1
• Gastrointestinal bleeding most common 1

Risk Mitigation:

• Proton pump inhibitor (PPI) mandatory with all DAPT regimens 1, 2
• Especially critical with history of GI bleeding 1
• Use radial (not femoral) arterial access for PCI 2

Drug-Specific Side Effects

Ticagrelor:

• Dyspnea (shortness of breath) 2
• Bradycardia 2

Prasugrel:

• Higher bleeding risk than clopidogrel 2
• Contraindicated with stroke/TIA history 2

Clopidogrel:

• Lowest bleeding risk among P2Y12 inhibitors 2
• Variable response due to genetic polymorphisms (CYP2C19) 3

When DAPT Can Be Stopped

Standard Discontinuation Timeline

After ACS:

• 12 months minimum for both BMS and DES 1, 2
• May extend beyond 12 months if no bleeding complications 1, 2
• Greatest benefit when P2Y12 inhibitor not discontinued or discontinued ≤30 days 1
• No benefit if discontinued >1 year before 1

After Elective PCI:

• BMS: 1 month minimum, ideally 12 months 1
• DES: 6 months minimum, ideally 12 months 1

Early Discontinuation Criteria

High Bleeding Risk Situations:

• Oral anticoagulation required 1
• Major intracranial surgery planned 1
• Significant overt bleeding occurs 1
• May discontinue at 3 months for DES if bleeding risk outweighs benefit 1

Perioperative Management:

• Do not perform elective surgery within 30 days of BMS 1
• Do not perform elective surgery within 3 months of DES 1
• Optimally delay 6 months after DES 1
• Continue aspirin if possible during surgery 1
• Restart P2Y12 inhibitor as soon as possible postoperatively 1
• Discontinue P2Y12 inhibitor 5-7 days preoperatively if necessary 1

What Is Taken After DAPT Discontinuation

Standard Post-DAPT Therapy

After 12 Months:

• Discontinue P2Y12 inhibitor, continue aspirin indefinitely 1
• Single antiplatelet therapy (aspirin 75-100 mg daily) recommended over continuing DAPT 1

Extended DAPT Consideration:

• May continue beyond 12 months if patient tolerates without bleeding 1
• Continuation beyond 12 months may be considered but not routinely recommended 1

Special Population: Triple Therapy Patients

When Anticoagulation Required:

• Limit triple therapy to maximum 6 months 2
• Use clopidogrel (not ticagrelor/prasugrel) as P2Y12 inhibitor 2
• Target INR 2.0-2.5 with warfarin 1, 2
• After triple therapy period: consider discontinuing aspirin 1-4 weeks post-PCI, continue P2Y12 inhibitor plus anticoagulant 2

Critical Pitfalls to Avoid

Medication Selection Errors:

• Never use prasugrel in patients with prior stroke/TIA 2
• Never use ticagrelor or prasugrel in triple therapy (excessive bleeding) 2
• Never use clopidogrel as first-line in ACS when ticagrelor/prasugrel available and not contraindicated 2

Duration Errors:

• Never discontinue DAPT prematurely without assessing bleeding vs thrombotic risk 1, 2
• Never perform elective surgery within minimum DAPT period 1

Bleeding Prevention Errors:

• Never omit PPI co-prescription with DAPT 1, 2
• Never use aspirin >100 mg daily (increases bleeding without benefit) 2