What alternatives to stenting do not require indefinite antiplatelet therapy for a patient with coronary artery disease?

Alternatives to Stenting That Do Not Require Indefinite Antiplatelet Therapy

Coronary artery bypass graft (CABG) surgery is the primary alternative to stenting that does not require indefinite dual antiplatelet therapy, requiring only lifelong aspirin monotherapy in most cases. 1

CABG: The Main Alternative

For patients undergoing CABG, lifelong single antiplatelet therapy (usually aspirin) is recommended, not indefinite dual antiplatelet therapy. 1 This represents a significant advantage over stenting, where dual antiplatelet therapy (DAPT) is required for 6-12 months minimum, and single antiplatelet therapy continues indefinitely thereafter. 1

Key Differences in Antiplatelet Requirements:

• CABG patients: Aspirin monotherapy indefinitely (Class I, Level A recommendation) 1
• Stent patients: DAPT for 6-12 months, then aspirin monotherapy indefinitely 1
• Medical therapy alone for ACS: DAPT for at least 12 months, then consideration for continuation 1

Medical Therapy Alone (Without Revascularization)

For patients with stable ischemic heart disease who have no history of myocardial infarction, percutaneous coronary intervention, or recent CABG, DAPT is not beneficial and should not be used. 1 These patients require only:

• Aspirin monotherapy 75-100 mg daily for secondary prevention (Class I recommendation) 1, 2
• Alternatively, clopidogrel 75 mg daily as monotherapy if aspirin is not tolerated (Class I, Level A recommendation) 2

This represents a true alternative where indefinite DAPT is avoided entirely.

Critical Timing Considerations for CABG

If a patient requires CABG after having received a coronary stent:

• Resume P2Y12 inhibitor postoperatively to complete the recommended duration of DAPT after the prior PCI 1
• For patients with recent ACS or recent PCI, DAPT should be continued for 12 months total, even after CABG 1
• For stable ischemic heart disease patients post-CABG without recent stenting, only aspirin monotherapy is needed 1

Important Caveats

The European Society of Cardiology strongly recommends against discontinuing all antiplatelet therapy after completing any revascularization strategy. 2 The distinction is:

• CABG alone: Single antiplatelet therapy (aspirin) indefinitely 1
• Stenting: DAPT for defined period, then single antiplatelet therapy indefinitely 1, 2
• Medical therapy for stable CAD without MI/PCI history: Single antiplatelet therapy only 1

Common Pitfall to Avoid:

Patients who undergo CABG and were previously on DAPT due to recent stenting should not have their P2Y12 inhibitor discontinued permanently after surgery. 1 The P2Y12 inhibitor should be resumed postoperatively to complete the full recommended DAPT duration from the time of stent placement. 1

Practical Algorithm for Decision-Making

For patients seeking to avoid indefinite DAPT:

1. If revascularization is needed and anatomy is suitable: Consider CABG over PCI, as this requires only aspirin monotherapy long-term 1

2. If patient has stable CAD without prior MI or revascularization: Medical therapy alone with aspirin monotherapy is appropriate 1

3. If stenting has already occurred: DAPT cannot be avoided for the initial 6-12 months minimum, but transitions to single antiplatelet therapy thereafter 1, 2

4. If patient is within 12 months of stent placement and requires surgery: Strong consideration should be given to delaying elective procedures until DAPT completion 1