Follow-Up After Cardiac Catheterization with Stent Placement
All patients who receive coronary stents must be maintained on dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor for 12 months unless there is excessive bleeding risk, followed by lifelong aspirin monotherapy. 1
Immediate Post-Procedure Antiplatelet Therapy
Standard DAPT Regimen (First-Line)
- Aspirin 75-100 mg daily should be initiated immediately and continued lifelong 1
- Plus one of the following P2Y12 inhibitors for 12 months:
Critical Timing Considerations
- For bare metal stents (BMS): Minimum 4-6 weeks of DAPT as endothelialization occurs, but 12 months is recommended for optimal outcomes 1
- For drug-eluting stents (DES): Minimum 12 months of DAPT is mandatory due to delayed endothelialization 1, 2
- Early discontinuation of clopidogrel within 6 months is the strongest predictor of stent thrombosis (hazard ratio 13.74), with 45% case fatality rate 1, 2
High Bleeding Risk Modifications
If bleeding risk outweighs ischemic benefit (PRECISE-DAPT score ≥25):
- Discontinue DAPT at 1-3 months and continue single antiplatelet therapy 1
- Always continue at least aspirin if clopidogrel must be stopped to minimize stent thrombosis risk 3
- Add proton pump inhibitor for gastrointestinal bleeding prevention during combined antithrombotic therapy 1
Long-Term Maintenance (After 12 Months)
Antiplatelet Therapy
- Aspirin 75-100 mg daily indefinitely is the standard after completing DAPT 1
- Clopidogrel 75 mg daily is an acceptable alternative to aspirin monotherapy if aspirin is not tolerated 1
Secondary Prevention Measures
- Cardiac rehabilitation program participation to improve outcomes 1
- High-intensity statin therapy targeting LDL-C <1.4 mmol/L (55 mg/dL) with ≥50% reduction from baseline 1
- Add ezetimibe if LDL-C goal not achieved with maximum tolerated statin dose 1
- Reinforce lifestyle modifications: 150-300 minutes/week moderate-intensity aerobic exercise 1
Clinical Follow-Up Schedule
Surveillance Monitoring
- Assess cardiovascular risk factors and medication adherence at least yearly 1
- Monitor for anginal symptoms and adjust antianginal therapy as needed 1
- Screen for bleeding complications, especially during DAPT period 1
Patient Counseling Imperatives
- Counsel patients never to discontinue antiplatelet therapy without cardiologist consultation 2, 3
- Emphasize that premature DAPT cessation dramatically increases stent thrombosis risk 1, 2
- Discuss importance of compliance with all secondary prevention medications 1
Special Situations
Patients Requiring Oral Anticoagulation
- Use DOAC (preferred) or VKA at therapeutic dose alone for chronic coronary syndrome with atrial fibrillation 1
- After PCI with OAC indication: low-dose aspirin + clopidogrel + OAC initially 1
- Stop aspirin within ≤1 week post-PCI, continue clopidogrel + OAC for 6-12 months depending on ischemic risk, then OAC alone 1
- Avoid ticagrelor or prasugrel with triple therapy due to excessive bleeding risk 1
Perioperative Management
- Elective non-cardiac surgery should be delayed: minimum 6 weeks for BMS, ideally 1 year for DES 3
- If surgery cannot be delayed and clopidogrel must be stopped, continue aspirin perioperatively 3
- Highest mortality occurs with surgery <30 days after stent placement 3
Common Pitfalls to Avoid
- Never discontinue DAPT early without assessing bleeding vs. ischemic risk - this is the leading cause of preventable stent thrombosis 1, 2
- Do not use prasugrel before knowing coronary anatomy - it is contraindicated in this setting 1
- Avoid combining ticagrelor/prasugrel with oral anticoagulation - use clopidogrel instead 1
- Do not forget proton pump inhibitor in patients at increased GI bleeding risk on combined antithrombotic therapy 1