What medications should a coronary artery disease (CAD) patient with a history of myocardial infarction, left ventricular dysfunction, or hypertension be prescribed following stent placement?

Post-Stent Medication Regimen for CAD Patients

All CAD patients following stent placement must be on dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor, with the specific regimen and duration determined by whether the presentation was acute coronary syndrome (ACS) or stable coronary artery disease (SCAD). 1

Immediate Post-Stent Antiplatelet Therapy

For ACS Patients (NSTEMI, STEMI, Unstable Angina)

First-line P2Y12 inhibitor selection:

• Ticagrelor (180 mg loading dose, then 90 mg twice daily) plus aspirin (75-100 mg daily) is the preferred regimen for all ACS patients regardless of whether they received prior clopidogrel 1, 2, 3
• Alternative: Prasugrel (60 mg loading dose, then 10 mg daily) plus aspirin for P2Y12-naïve patients undergoing PCI, unless contraindicated 1, 2
• Clopidogrel (600 mg loading dose, then 75 mg daily) should only be used when ticagrelor or prasugrel are unavailable or contraindicated 1

Duration: 12 months minimum for all ACS patients regardless of stent type 1, 2

For Stable CAD (Elective PCI)

• Clopidogrel (600 mg loading dose, then 75 mg daily) plus aspirin is the standard regimen 1
• Aspirin loading dose: 150-300 mg oral (or 75-250 mg IV if not pre-treated), then 75-100 mg daily 1
• Duration: 6 months minimum for stable CAD patients with standard stents 1
• Consider ticagrelor or prasugrel only in high-risk situations (history of stent thrombosis, left main stenting) 1

Critical Contraindications and Dose Adjustments

Prasugrel must NOT be given to:

• Patients with prior stroke or TIA (increases cerebrovascular events: 6.5% vs 1.2% with clopidogrel) 4, 5
• Patients ≥75 years old (increased fatal and intracranial bleeding) 3, 4
• Patients <60 kg body weight (consider 5 mg maintenance dose instead of 10 mg) 4

Bleeding Risk Mitigation Strategies

Mandatory interventions to reduce bleeding:

• Prescribe a proton pump inhibitor (PPI) with all DAPT regimens to reduce gastrointestinal bleeding 2, 3
• Maintain aspirin at 75-100 mg daily (not higher doses) when combined with P2Y12 inhibitors 1, 2
• Use radial over femoral access for procedures when performed by expert radial operators 1, 3

For high bleeding risk patients (PRECISE-DAPT score ≥25):

• Consider shortened DAPT duration to 3-6 months in stable CAD 1
• Consider shortened DAPT duration to 6 months in ACS 3
• Prefer clopidogrel over more potent P2Y12 inhibitors 3

Extended DAPT Considerations (Beyond 12 Months)

For patients who tolerate 12 months of DAPT without bleeding complications and are not at high bleeding risk:

• Continuation beyond 12 months may be reasonable in ACS patients at low bleeding risk but high thrombotic risk 1, 6
• Consider reduced-dose ticagrelor 60 mg twice daily (instead of 90 mg) for extended therapy in post-MI patients 7
• In stable CAD, continuation with clopidogrel for up to 30 months may be considered 1

Additional Cardiovascular Medications

Beyond antiplatelet therapy, CAD patients with the specified comorbidities require:

For All Post-MI or LV Dysfunction Patients:

• Beta-blocker therapy (reduces mortality post-MI)
• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
• ACE inhibitor or ARB (especially with LV dysfunction, EF <40%, hypertension, or diabetes)

For Hypertensive Patients:

• ACE inhibitor or ARB as first-line for CAD patients with hypertension
• Target blood pressure <130/80 mmHg

For LV Dysfunction (EF <40%):

• Aldosterone antagonist (spironolactone or eplerenone) if EF ≤35% post-MI
• Consider SGLT2 inhibitor for heart failure with reduced ejection fraction

Critical Pitfalls to Avoid

Never discontinue DAPT prematurely:

• Premature discontinuation is the leading predictor of stent thrombosis with mortality rates of 20-45% 6
• Stent thrombosis occurs in up to 29% of patients who prematurely discontinue DAPT 6
• If elective surgery is needed, postpone for 12 months after DES placement if possible 6
• Minimum 1 month of DAPT is absolutely required even in highest bleeding risk scenarios 1

Do not use prasugrel in medically managed ACS patients (only for those undergoing PCI) 2

Do not omit PPI prescription - this simple intervention significantly reduces GI bleeding without compromising antiplatelet efficacy 2, 3

If CABG is needed:

• Discontinue prasugrel at least 7 days prior to surgery 4
• Resume P2Y12 inhibitor after CABG to complete 12 months of DAPT in ACS patients 1

Special Population: Triple Therapy (DAPT + Anticoagulation)

For patients requiring oral anticoagulation:

• Discontinue aspirin 1-4 weeks after PCI 2, 3
• Continue P2Y12 inhibitor (preferably clopidogrel rather than ticagrelor due to lower bleeding risk) 2, 3
• Keep triple therapy duration as short as possible 6

Long-Term Management (After DAPT Completion)

After completing recommended DAPT duration:

• Continue aspirin indefinitely (lifelong single antiplatelet therapy) 1, 6
• Continue statin, beta-blocker, and ACE inhibitor/ARB as indicated by comorbidities