What medications, in addition to antiplatelet therapy, are typically prescribed to a patient who has undergone angioplasty to reduce the risk of further cardiovascular events?

Medications After Angioplasty for Cardiovascular Event Prevention

In addition to dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor), patients who have undergone angioplasty should be prescribed a high-intensity statin, and in most cases, an ACE inhibitor or ARB, along with a beta-blocker if there is a history of myocardial infarction or left ventricular dysfunction. 1, 2

Core Medication Classes

Lipid-Lowering Therapy: Statins (Essential for All Patients)

• High-intensity statin therapy is recommended for all patients after PCI to reduce LDL-cholesterol below 100 mg/dL, with consideration of a target below 70 mg/dL for very high-risk patients 1, 2
• Atorvastatin 40-80 mg daily or rosuvastatin 20-40 mg daily are the preferred high-intensity options 3
• Continue statins that were started before the procedure, and initiate statins perioperatively in patients undergoing vascular procedures if not already prescribed 1
• Statins have demonstrated clear mortality and morbidity benefits in secondary prevention after coronary revascularization 2, 4

Antihypertensive Therapy: Beta-Blockers and ACE Inhibitors/ARBs

Beta-blockers:

• Continue beta-blockers in patients already on chronic therapy, and initiate them in patients with prior myocardial infarction or left ventricular systolic dysfunction 1
• Beta-blockers should be started as early as clinically feasible after ACS and continued long-term 1, 2
• Avoid initiating beta-blockers on the day of surgery if non-cardiac surgery is planned 1

ACE Inhibitors or ARBs:

• Recommended for patients with hypertension, diabetes, left ventricular systolic dysfunction, or chronic kidney disease 1, 2
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively, and they should be restarted as soon as clinically feasible postoperatively if held 1
• These agents reduce cardiovascular events and mortality in high-risk patients after revascularization 2

Antiplatelet Therapy Duration and Specifics

Dual antiplatelet therapy (DAPT) duration:

• For ACS patients: Continue DAPT (aspirin plus P2Y12 inhibitor) for 12 months after PCI with stenting 1
• For stable coronary disease: Continue DAPT for 6 months after PCI with stenting 1, 5
• After completing the recommended DAPT duration, transition to aspirin monotherapy 75-100 mg daily indefinitely 1, 5

P2Y12 inhibitor selection:

• Prasugrel 10 mg daily (5 mg if age ≥75 years or weight <60 kg) or ticagrelor 90 mg twice daily are preferred over clopidogrel 75 mg daily in ACS patients 1
• Clopidogrel 75 mg daily is acceptable when prasugrel or ticagrelor are contraindicated, not tolerated, or unavailable 1

Special Circumstances

Patients Requiring Oral Anticoagulation (e.g., Atrial Fibrillation)

• Triple therapy (aspirin + P2Y12 inhibitor + oral anticoagulant) should be minimized to the shortest duration possible, typically discontinued at hospital discharge for most patients 6
• After discharge, continue dual therapy with a NOAC (preferably apixaban) and clopidogrel for 6-12 months based on presentation 1, 6
• After completing dual therapy, continue the oral anticoagulant alone for stroke prevention 6

Patients with Peripheral Artery Disease After Angioplasty

• For patients with severe PAD and high ischemic risk without high bleeding risk, add low-dose rivaroxaban 2.5 mg twice daily to aspirin 100 mg daily after completing the standard DAPT period 7
• This dual pathway inhibition reduces major adverse cardiovascular events and major adverse limb events 7

Critical Pitfalls to Avoid

• Never discontinue antiplatelet therapy for diagnostic procedures alone—the bleeding risk is minimal compared to the catastrophic risk of stent thrombosis 5
• Do not use oral anticoagulation with warfarin alone for secondary prevention after PCI without another indication (e.g., atrial fibrillation), as it increases bleeding without reducing cardiovascular events 1, 7
• Avoid long-term dual antiplatelet therapy beyond 12 months in most patients due to increased bleeding risk without proven benefit, unless the patient has very high ischemic risk and low bleeding risk 1, 8
• Do not start beta-blockers on the day of non-cardiac surgery if perioperative initiation is planned 1

Monitoring Requirements

• Assess bleeding risk using validated scores such as PRECISE-DAPT, and evaluate renal function regularly as it affects medication dosing 6
• Monitor for signs of bleeding and reassess the need for continued dual therapy at 6 and 12 months 6
• Check lipid panels to ensure LDL-cholesterol targets are achieved, and monitor liver enzymes and creatine kinase if statin-related symptoms develop 3