Medication Management After Angioplasty
All patients with a history of angioplasty (PCI) with stent placement must be prescribed dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor to prevent stent thrombosis, myocardial infarction, and death. 1
Core Antiplatelet Regimen
Aspirin
- Loading dose: 162-325 mg before or at the time of PCI 1
- Maintenance dose: 81 mg daily indefinitely (preferred long-term dose to reduce bleeding risk) 1
- Aspirin should be continued for life after stent placement 1
P2Y12 Inhibitor Selection
You have three options for the P2Y12 inhibitor component, with prasugrel or ticagrelor preferred over clopidogrel for acute coronary syndrome (ACS) patients due to superior efficacy 2:
Clopidogrel:
Prasugrel (more potent, faster acting):
- Loading dose: 60 mg at time of PCI 1, 3
- Maintenance: 10 mg daily 1, 3
- Contraindicated in patients with prior stroke/TIA (increased cerebrovascular event risk: 6.5% vs 1.2%, P=0.002) 1, 2
- Avoid in patients >75 years old or <60 kg body weight 2
Ticagrelor:
- Loading dose: 180 mg 1
- Maintenance: 90 mg twice daily 1
- Use with low-dose aspirin (81 mg) specifically 1
The ISAR-REACT-5 trial demonstrated prasugrel reduced death, MI, or stroke compared to ticagrelor (6.9% vs 9.3%, P=0.006) with no significant difference in bleeding 2.
Duration of Dual Antiplatelet Therapy
Drug-Eluting Stents (DES)
- Minimum duration: 12 months 1, 4
- Continue both aspirin and P2Y12 inhibitor for the full year 1, 4
- After 12 months, transition to aspirin monotherapy indefinitely 4
Bare-Metal Stents (BMS)
- Minimum duration: 1 month, ideally up to 12 months 1, 4
- For high bleeding risk patients: minimum 2 weeks 4
Critical pitfall: Premature discontinuation of DAPT is the single most significant risk factor for stent thrombosis, which carries high mortality 4, 5. The risk of coronary thrombosis from stopping antiplatelet therapy far exceeds the risk of surgical bleeding from continuing it 5.
High Bleeding Risk Modifications
If the patient has high bleeding risk (defined as ≥4% annual risk of serious bleeding or ≥1% risk of intracranial hemorrhage), consider 2:
- Shorter DAPT duration: 3-6 months depending on stent type 4, 2
- Use bare-metal stents instead of drug-eluting stents 1
High-risk features include: age ≥65 years, BMI <18.5, diabetes, prior bleeding, concurrent oral anticoagulation, or weight <60 kg 2.
Additional Cardiovascular Risk Reduction
Statin Therapy
- High-intensity statin therapy should be initiated or continued in all post-PCI patients 1
- This is a Class I recommendation regardless of lipid levels 1
Patients with Diabetes
- Consider adding SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit for additional risk reduction 1
Special Situations
Atrial Fibrillation Requiring Anticoagulation
- After 1-4 weeks of triple therapy (aspirin + P2Y12 inhibitor + anticoagulant), discontinue aspirin while maintaining P2Y12 inhibitor plus anticoagulant 1
- This reduces bleeding risk while maintaining thrombotic protection 1
Planned Surgery
- Do not stop DAPT without cardiology consultation 6, 5
- If surgery cannot be delayed, maintain aspirin if possible and stop P2Y12 inhibitor 6
- Clopidogrel/ticagrelor: stop 5 days before surgery 1, 6
- Prasugrel: stop 7 days before surgery 1, 6
- Resume P2Y12 inhibitor within 12-24 hours post-operatively when hemostasis achieved 6
Concomitant Medications to Avoid
- Do not use omeprazole or esomeprazole with clopidogrel (they inhibit CYP2C19 and reduce clopidogrel effectiveness) 7
- Use alternative proton pump inhibitors if GI protection needed 7
- Avoid chronic NSAIDs due to increased bleeding risk 3
Monitoring and Follow-Up
- Counsel patients on bleeding precautions: expect easier bruising, longer bleeding times, and to report any unexplained or prolonged bleeding 3
- Emphasize the critical importance of medication adherence before stent implantation 4
- Monitor for signs of stent thrombosis even beyond 12 months, particularly with drug-eluting stents 4