What types of stents do not require antiplatelet therapy, such as dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (e.g. clopidogrel), after placement?

What Stents Don't Require Antiplatelet Medication Afterwards

No coronary stents are exempt from antiplatelet therapy—all coronary stents require at least some duration of antiplatelet medication to prevent stent thrombosis, which carries a 40-64% risk of death or myocardial infarction. 1

Bare-Metal Stents (BMS): Shortest Duration Required

Bare-metal stents require the shortest duration of dual antiplatelet therapy (DAPT)—only 1 month—making them the closest option to "not requiring" prolonged antiplatelet therapy. 1

BMS Antiplatelet Protocol:

• DAPT (aspirin + clopidogrel) for 1 month minimum 1
• Aspirin monotherapy indefinitely thereafter 1
• Loading doses: aspirin 325 mg + clopidogrel 600 mg at time of stenting 1
• Maintenance: aspirin 75-100 mg daily + clopidogrel 75 mg daily 1

When BMS Should Be Used:

• Patients with high bleeding risk 1
• Patients requiring urgent major surgery within 12 months 1
• Patients unable to comply with prolonged DAPT 1
• Patients on chronic oral anticoagulation 1, 2

Critical caveat: BMS are now used in less than 15% of cases in the UK, and many centers no longer stock them because drug-eluting stents have superior outcomes in most patients. 1

Drug-Eluting Stents (DES): Longer Duration Required

All drug-eluting stents require significantly longer DAPT duration and cannot be considered as "not requiring" antiplatelet therapy:

Standard DES Protocol:

• DAPT for 6-12 months minimum 1
• Aspirin monotherapy indefinitely thereafter 1
• Specific durations historically varied by stent type: sirolimus DES (3 months), paclitaxel DES (6 months), but current guidelines recommend 12 months for all DES 1

Special DES: BioFreedom Polymer-Free Stents

BioFreedom drug-eluting stents are polymer-free and licensed for only 1 month of DAPT (same as bare-metal stents), making them an option for high-bleeding-risk patients who need the restenosis benefits of drug-eluting technology. 1

The Catastrophic Risk of Premature DAPT Discontinuation

Stopping antiplatelet therapy prematurely is the single strongest predictor of stent thrombosis, with a hazard ratio of 161 for subacute thrombosis and 57 for late thrombosis. 1

Documented Consequences:

• 29% of patients who prematurely discontinued DAPT developed stent thrombosis 1
• Mortality rate from stent thrombosis: 20-45% 1
• Death or MI rate with documented stent thrombosis: 64.4% 1
• 7.5% mortality in patients who stopped thienopyridine therapy vs. 0.7% in those who continued (hazard ratio 9.0) 1

Special Populations Requiring Modified Antiplatelet Regimens

Patients on Chronic Oral Anticoagulation:

Triple therapy (warfarin + aspirin + clopidogrel) significantly increases bleeding risk, so duration must be minimized. 1, 3, 2

• Use bare-metal stents or BioFreedom DES when possible 1, 2
• Triple therapy for 1 month only (for BMS), then warfarin + clopidogrel alone 1, 2
• For standard DES: triple therapy for 6 months maximum, then warfarin + single antiplatelet agent 1
• Aspirin dose should be reduced to 75-100 mg daily when combined with anticoagulation 1
• Clopidogrel is preferred over prasugrel or ticagrelor due to lower bleeding risk 1

Patients Requiring Urgent Surgery:

When emergency surgery is necessary within 30 days of stenting, the patient proceeds to surgery without stopping antiplatelet therapy if bleeding risk permits. 1

• If surgery can be deferred 30 days: use BMS and stop DAPT after 30 days 1
• If surgery requires stopping P2Y12 inhibitor: continue aspirin if bleeding risk is not prohibitive 1
• Stop clopidogrel 7 days before elective procedures (5-7 days for platelet function to normalize) 1
• No validated "bridging" strategy exists for coronary stents (unlike intracranial stents where GP IIb/IIIa inhibitors have been used) 1, 4

Intracranial Stents: Different Requirements

Intracranial stents follow similar but distinct protocols and are NOT first-line therapy for intracranial stenosis. 5

Intracranial Stent Protocol:

• Bare-metal intracranial stents: DAPT for minimum 4 weeks 5
• Drug-eluting intracranial stents: DAPT for 6-12 months 5
• Aspirin monotherapy indefinitely thereafter 5
• Critical: Aggressive medical management is superior to intracranial stenting for recently symptomatic stenosis 5

Bottom Line Algorithm

To minimize antiplatelet therapy duration after coronary stenting:

1. Use bare-metal stents (1 month DAPT) if:

   • High bleeding risk 1
   • Surgery needed within 12 months 1
   • Chronic anticoagulation required 1, 2
   • Unable to afford or comply with prolonged DAPT 1

2. Consider BioFreedom polymer-free DES (1 month DAPT) if:

   • High bleeding risk but need restenosis reduction benefits 1

3. Never use any stent if:

   • Patient cannot tolerate or comply with at least 1 month of DAPT 1
   • Consider balloon angioplasty alone in emergency surgery situations 1

There is no coronary stent that eliminates the need for antiplatelet therapy entirely—the minimum is always 1 month of DAPT followed by indefinite aspirin monotherapy. 1