How long should a patient with a coronary stent placement stay on Plavix (clopidogrel) after being initially prescribed for only three weeks?

Duration of Plavix (Clopidogrel) After Coronary Stent Placement

If this patient received a coronary stent, Plavix should be continued for at least 12 months regardless of stent type (bare-metal or drug-eluting), not just three weeks. 1, 2

Critical Context: Three Weeks is Dangerously Inadequate

• Premature discontinuation of clopidogrel is one of the most significant risk factors for stent thrombosis, which can result in myocardial infarction and death 2
• Three weeks falls far short of even the absolute minimum duration for any stent type 1
• The patient needs immediate clarification about why they were prescribed only three weeks, as this may represent a prescribing error or miscommunication 2

Evidence-Based Duration Guidelines

For Drug-Eluting Stents (DES)

• Minimum duration: 12 months of clopidogrel 75 mg daily if the patient is not at high bleeding risk 1, 2
• This applies to both ACS and non-ACS indications for DES placement 1
• Continuation beyond 12 months may be considered but remains optional 1

For Bare-Metal Stents (BMS)

• Minimum duration: 1 month, ideally extended to 12 months unless high bleeding risk exists 1, 2
• For patients at increased bleeding risk with BMS, the absolute minimum is 2 weeks—still longer than the three weeks prescribed 1, 2

For Acute Coronary Syndrome (ACS) Patients

• Mandatory 12-month duration regardless of stent type (BMS or DES) 1
• Options include clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily 1

When Earlier Discontinuation May Be Considered

• Only if bleeding risk clearly outweighs ischemic benefit should discontinuation before 12 months be considered 1, 2
• Even in high bleeding risk scenarios, the minimum durations are: 2 weeks for BMS and 3-6 months for DES depending on stent type 1, 2
• This decision requires careful discussion with the interventional cardiologist who performed the procedure 1, 2

Supporting Evidence from Clinical Trials

• The DAPT trial demonstrated that continuing dual antiplatelet therapy beyond 12 months (to 30 months) significantly reduced stent thrombosis (0.4% vs 1.4%, p<0.001) and major adverse cardiovascular events (4.3% vs 5.9%, p<0.001) compared to aspirin alone 3
• However, extended therapy increased moderate-to-severe bleeding (2.5% vs 1.6%, p=0.001) 3
• This supports the standard 12-month recommendation as balancing efficacy and safety 4, 5

Aspirin Continuation

• Aspirin should be continued indefinitely after completing the clopidogrel course 1, 2
• Low-dose aspirin (81 mg daily) is preferred over higher doses for long-term therapy 1, 2

Immediate Action Required

• Contact the prescribing physician or interventional cardiologist immediately to clarify the intended duration 2
• Verify the stent type (BMS vs DES), indication (ACS vs non-ACS), and bleeding risk assessment 1
• Do not discontinue clopidogrel at three weeks without explicit discussion with cardiology 1, 2
• Counsel the patient on the critical importance of medication compliance and the severe consequences of premature discontinuation 1, 2

Common Pitfalls to Avoid

• Never assume a short prescription duration is intentional—it may represent a prescribing error or insurance authorization issue 2
• The risk of late stent thrombosis extends well beyond the initial weeks after stent placement, particularly with drug-eluting stents 2, 3
• Patients requiring non-cardiac surgery should have the procedure delayed until completing appropriate dual antiplatelet therapy duration whenever possible 2