What are the guidelines for choosing the type of stent and antiplatelet therapy for a patient requiring stent placement, considering individual patient characteristics and clinical scenario?

Stent Selection and Antiplatelet Therapy Guidelines

Stent Type Selection

Newer-generation drug-eluting stents (DES) should be the default choice for nearly all patients requiring coronary stenting, regardless of bleeding risk, as the need for short DAPT duration no longer justifies bare metal stent (BMS) use. 1

Key Principles for Stent Choice:

• DES over BMS in all scenarios: Modern DES platforms allow for abbreviated DAPT regimens (1-3 months) in high bleeding risk patients while maintaining superior efficacy compared to BMS 1
• DAPT duration should guide stent selection, not vice versa: The stent type should not determine antiplatelet therapy duration; rather, individual ischemic and bleeding risk assessment should dictate DAPT duration regardless of stent implanted 1
• BMS no longer preferred even in high bleeding risk: Contemporary guidelines have moved away from BMS selection based solely on anticipated short DAPT duration 1

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Antiplatelet Therapy Selection and Duration

P2Y12 Inhibitor Choice:

For acute coronary syndrome (ACS) patients, ticagrelor or prasugrel is recommended unless specific contraindications exist; clopidogrel is the default for stable CAD, patients requiring oral anticoagulation, or when potent P2Y12 inhibitors are contraindicated. 1

Specific Agent Selection:

• Prasugrel: Indicated for ACS patients undergoing PCI with 60 mg loading dose, then 10 mg daily; contraindicated in patients with prior stroke/TIA, age ≥75 years (except high-risk diabetes/prior MI), or weight <60 kg (consider 5 mg dose) 2
• Ticagrelor: Recommended for ACS unless contraindicated 1
• Clopidogrel: Default for stable CAD, patients on oral anticoagulation, and when ticagrelor/prasugrel contraindicated 1

DAPT Duration by Clinical Scenario:

Stable Coronary Artery Disease (SCAD):

• Standard duration: 1-6 months depending on bleeding risk 1
• High bleeding risk: 1 month minimum acceptable 1
• Low bleeding risk with high ischemic risk: Consider extending beyond 6 months 1

Acute Coronary Syndromes (ACS):

• Default duration: 12 months irrespective of revascularization strategy (medical therapy, PCI, or CABG) 1
• High bleeding risk: Consider shortening to 6 months 1
• Patients tolerating DAPT without bleeding: Consider extending beyond 12 months 1

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Special Populations

Patients Requiring Oral Anticoagulation (OAC):

Triple antithrombotic therapy (OAC + aspirin + P2Y12 inhibitor) should be limited to a maximum of 1 month in most patients, with transition to dual therapy (OAC + single antiplatelet agent) thereafter. 1

Triple Therapy Management:

• Standard approach: 1 month triple therapy (OAC + aspirin + clopidogrel) regardless of stent type 1
• High ischemic risk (ACS, complex anatomy): May extend to 6 months if ischemic risk outweighs bleeding risk 1
• High bleeding risk: Avoid triple therapy entirely; use dual therapy with OAC + clopidogrel from discharge 1

After Triple Therapy Period:

• Months 1-12: Dual antithrombotic therapy (OAC + aspirin OR clopidogrel) 1
• After 12 months: OAC monotherapy 1

Critical Restrictions:

• Never use ticagrelor or prasugrel as part of triple antithrombotic therapy 1
• Clopidogrel is the only acceptable P2Y12 inhibitor with OAC 1
• DOAC preferred over warfarin: Use lowest approved dose for stroke prevention when combined with antiplatelet drugs 1
• Rivaroxaban dosing: Consider 15 mg once daily instead of 20 mg when combined with antiplatelet therapy 1

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Perioperative Management

Elective Surgery After Stent Placement:

Surgery should be delayed until at least 1 month post-stenting if aspirin can be continued; if both antiplatelet agents must be stopped, delay until at least 3 months post-stenting. 1

Timing-Based Recommendations:

• <6 weeks post-stent: Continue both aspirin and P2Y12 inhibitor through surgery if possible 1
• 6-12 weeks post-stent: Either continue both agents OR stop one agent (typically P2Y12 inhibitor) 7-10 days before surgery 1
• 3-12 months post-stent: Stop P2Y12 inhibitor 7-10 days pre-operatively; continue aspirin 1

Factors Influencing Decision:

• Timing of stent placement: Closer to 6 weeks versus 12 weeks 1
• Stent location: Critical vessel location (left main, proximal LAD) increases risk 1
• Number and length of stents: Multiple or long stents increase thrombotic risk 1

Bridging Therapy:

Routine bridging with glycoprotein IIb/IIIa inhibitors, cangrelor, or LMWH is NOT recommended; consider only in highly selected patients with recent stent (<3 months) in critical location. 1

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Bleeding Risk Mitigation Strategies

Every patient on DAPT requires systematic bleeding risk reduction measures including proton pump inhibitor (PPI) use, low-dose aspirin (75-100 mg), radial access for procedures, and correction of modifiable bleeding risk factors. 1

Mandatory Risk Reduction:

• PPI therapy: Routine use in all patients on DAPT 1
• Aspirin dosing: Use lowest effective dose (75-100 mg daily) 1
• Access site selection: Radial over femoral approach when feasible 1
• Avoid NSAIDs: Acetaminophen preferred for pain management in patients with stents 3

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Risk Stratification Framework

Ischemic Risk Assessment:

High ischemic risk patients (prior ACS/MI, diabetes, multivessel disease, complex lesions) warrant longer DAPT duration, while low ischemic risk (stable CAD, simple lesions) allows for shorter duration. 1

Bleeding Risk Assessment:

High bleeding risk factors include age >75 years, weight <60 kg, prior bleeding, chronic kidney disease, concomitant anticoagulation, and planned surgery—these patients require abbreviated DAPT (1-3 months). 1, 2

Dynamic Reassessment:

• Ischemic and bleeding risks change over time: Reassess at each clinical encounter 1
• Competing risks often coexist: When risks are balanced, favor shorter DAPT to minimize bleeding 1