Antiplatelet Therapy After Bifurcation PCI
For patients undergoing PCI with stenting for coronary bifurcation lesions, the antiplatelet regimen is identical to standard PCI protocols and is determined by clinical presentation (stable CAD vs. ACS), not by lesion complexity or bifurcation anatomy.
Clinical Presentation-Based Approach
Acute Coronary Syndrome (ACS) Patients
Ticagrelor (180 mg loading dose, 90 mg twice daily) plus aspirin (75-100 mg daily) for 12 months is the first-line regimen for all ACS patients undergoing bifurcation PCI, regardless of stenting technique used. 1, 2
Prasugrel (60 mg loading, 10 mg daily) plus aspirin is an alternative for P2Y12 inhibitor-naïve patients with NSTE-ACS or STEMI undergoing PCI, unless contraindications exist (prior stroke/TIA, age ≥75 years, weight <60 kg) 1, 3
Clopidogrel (600 mg loading, 75 mg daily) plus aspirin should be reserved only for patients who cannot receive ticagrelor or prasugrel due to contraindications, prior intracranial bleeding, or need for oral anticoagulation 1, 2
The 12-month duration applies regardless of whether single-stent or two-stent techniques were used for the bifurcation 1
Stable Coronary Artery Disease (SCAD) Patients
Clopidogrel (600 mg loading, 75 mg daily) plus aspirin (75-100 mg daily) for 6 months is the standard regimen for elective bifurcation PCI, irrespective of stent type or bifurcation complexity. 1
This 6-month duration applies whether bare-metal stents, drug-eluting stents, or drug-coated balloons were used 1
Ticagrelor or prasugrel may be considered only in specific high-risk situations such as left main bifurcation stenting or history of stent thrombosis 1
Duration Modifications Based on Bleeding Risk
High Bleeding Risk Patients (PRECISE-DAPT ≥25)
In SCAD patients with high bleeding risk, shorten DAPT to 3 months 1
In ACS patients with high bleeding risk, consider shortening DAPT to 6 months 1
If 3-month DAPT poses safety concerns in SCAD, 1-month DAPT may be considered 1
Low Bleeding Risk with High Thrombotic Risk
In SCAD patients who tolerate DAPT without bleeding complications and have low bleeding risk but high thrombotic risk (complex bifurcation PCI, extensive disease), continuation of DAPT with clopidogrel for >6 months up to 30 months may be considered 1
In ACS patients who tolerate 12 months of DAPT without bleeding, prolongation beyond 12 months may be considered 1
Bleeding Risk Mitigation Strategies
All patients on DAPT should receive:
Aspirin dose limited to 75-100 mg daily (81 mg in US) when combined with any P2Y12 inhibitor 1, 2
Proton pump inhibitor co-prescription to reduce gastrointestinal bleeding risk 1, 2
Radial over femoral access when performed by an expert radial operator 1, 2
Critical Pitfalls to Avoid
Do not extend DAPT duration based solely on bifurcation complexity or two-stent technique - the evidence supporting DAPT duration is based on clinical presentation (ACS vs. SCAD) and bleeding/thrombotic risk, not anatomic complexity 1
Do not use clopidogrel as first-line therapy in ACS patients when ticagrelor or prasugrel are available and not contraindicated - this represents suboptimal care 1, 2
Do not discontinue DAPT prematurely, especially within the first month after stent placement, as this dramatically increases thrombotic risk regardless of lesion location 1, 2
Do not omit PPI co-prescription - this simple intervention significantly reduces gastrointestinal bleeding without compromising antiplatelet efficacy 1, 2