Management of Aspirin and DOAC Use in Patients with Established CAD and Previous Stent
Without Indication for Oral Anticoagulation
In patients with established CAD and previous stent placement who do NOT require oral anticoagulation, aspirin 75-100 mg daily is recommended lifelong after completing the initial dual antiplatelet therapy (DAPT) period. 1
Initial Post-Stenting Period (No OAC Indication)
- DAPT with aspirin 75-100 mg plus clopidogrel 75 mg daily for up to 6 months is the default strategy after stent placement in chronic coronary syndrome patients 1
- After 6 months, transition to single antiplatelet therapy (aspirin 75-100 mg daily) lifelong 1
- Clopidogrel 75 mg daily is an equally effective alternative to aspirin for long-term monotherapy if aspirin is not tolerated 1
High Bleeding Risk Patients
- In patients at high bleeding risk but not at high ischemic risk, discontinue DAPT after 1-3 months and continue single antiplatelet therapy 1
- Stopping DAPT after 1-3 months may be considered in patients who are neither at high bleeding risk nor high ischemic risk 1
WITH Indication for Oral Anticoagulation (e.g., Atrial Fibrillation)
After uncomplicated PCI in patients requiring long-term oral anticoagulation, stop aspirin within 1 week, continue DOAC plus clopidogrel 75 mg daily for 6-12 months (depending on ischemic risk), then transition to DOAC monotherapy. 1
Immediate Post-PCI Period (With OAC Indication)
- DOACs are strongly preferred over warfarin when eligible 1
- Initial triple therapy (aspirin + clopidogrel + DOAC) for ≤1 week only after uncomplicated PCI 1
- Early cessation of aspirin (≤1 week) is recommended after uncomplicated stenting 1
Dual Therapy Period (DOAC + Clopidogrel)
After stopping aspirin at 1 week:
- Continue DOAC plus clopidogrel 75 mg daily for up to 6 months in patients NOT at high ischemic risk 1
- Continue DOAC plus clopidogrel 75 mg daily for up to 12 months in patients at HIGH ischemic risk 1
- Ticagrelor or prasugrel are generally NOT recommended as part of triple or dual therapy with oral anticoagulation 1
Long-Term Maintenance (After 6-12 Months)
- Transition to DOAC monotherapy alone after completing the dual therapy period 1
- In CCS patients with long-term OAC indication, therapeutic-dose DOAC alone (or VKA alone) is recommended lifelong 1
DOAC Dose Adjustments During Dual Therapy
When bleeding risk concerns prevail over thrombotic risk during the period of combined antiplatelet therapy:
- Rivaroxaban 15 mg daily should be considered instead of 20 mg daily for the duration of concomitant antiplatelet therapy 1
- Dabigatran 110 mg twice daily should be considered instead of 150 mg twice daily for the duration of concomitant antiplatelet therapy 1
Special Consideration: Adding Aspirin to Long-Term OAC
Aspirin 75-100 mg daily (or clopidogrel 75 mg daily) may be considered in ADDITION to long-term OAC in patients with AF, history of MI, and at high risk of recurrent ischemic events who do NOT have high bleeding risk. 1
This represents a potential exception where dual therapy (OAC + aspirin) continues beyond the standard 6-12 month period, but only in highly selected patients with:
- Atrial fibrillation requiring anticoagulation
- History of myocardial infarction
- High risk of recurrent ischemic events
- Low bleeding risk 1
Rivaroxaban 2.5 mg Plus Aspirin for Stable CAD (Alternative Strategy)
In patients with stable CAD (including those with previous stent >1 year ago) who do NOT require therapeutic anticoagulation for other indications, rivaroxaban 2.5 mg twice daily plus aspirin 75-100 mg once daily may be considered to reduce major cardiovascular events. 1, 2
This combination:
- Reduces cardiovascular death, MI, and stroke compared to aspirin alone 2, 3
- Increases major bleeding risk compared to aspirin monotherapy 2, 3
- Is FDA-approved for reduction of major cardiovascular events in CAD patients 2
- Should be reserved for patients at high ischemic risk and low bleeding risk 1, 3
The net clinical benefit analysis shows that per 10,000 patient-years of treatment, this combination prevents 70 cardiovascular events but causes 12 additional life-threatening bleeds 2
Critical Pitfalls to Avoid
- Never discontinue antiplatelet therapy prematurely in the first 6-12 months post-stenting, as this is the most powerful predictor of stent thrombosis with mortality rates up to 20% 4, 5, 6
- Do NOT use triple therapy (aspirin + P2Y12 inhibitor + OAC) beyond 1 week after uncomplicated PCI in patients requiring anticoagulation 1
- Do NOT use ticagrelor or prasugrel as part of triple antithrombotic therapy with aspirin and OAC 1
- Always add a proton pump inhibitor for gastrointestinal protection during DAPT or combination antithrombotic therapy 1
- Avoid omeprazole/esomeprazole with clopidogrel due to CYP2C19 interaction; use pantoprazole or lansoprazole instead 4, 5, 6