Aspirin as Antiplatelet Therapy After Stent Placement
Both bare-metal stents (BMS) and drug-eluting stents (DES) require aspirin as part of their antiplatelet regimen, and aspirin should be continued indefinitely after placement of either stent type. 1
Initial Dual Antiplatelet Therapy Requirements
Bare-Metal Stents (BMS)
- First month: Aspirin 162-325 mg daily plus clopidogrel 75 mg daily (Grade 1A recommendation) 1
- Months 2-12: Aspirin 75-162 mg daily plus clopidogrel 75 mg daily (Grade 2C recommendation) 1
- After 12 months: Aspirin alone indefinitely (Grade 1B recommendation) 1
Drug-Eluting Stents (DES)
- First 3-6 months: Aspirin 162-325 mg daily plus clopidogrel 75 mg daily (Grade 1A recommendation) 1
- Minimum duration varies by stent type: 3 months for sirolimus-eluting stents (-limus stents) and 6 months for paclitaxel-eluting stents (-taxel stents) 1
- Months 3-12: Aspirin 75-162 mg daily plus clopidogrel 75 mg daily (Grade 2C recommendation) 1
- After 12 months: Aspirin alone indefinitely (Grade 1B recommendation) 1, 2
Long-Term Aspirin Monotherapy
After the mandatory dual antiplatelet therapy period ends, aspirin monotherapy should be continued indefinitely for both BMS and DES patients. 1, 2 The recommended long-term aspirin dose is 75-162 mg daily, with 81 mg being the preferred dose in current practice. 1, 2
Critical Safety Considerations
Premature discontinuation of dual antiplatelet therapy dramatically increases the risk of stent thrombosis, which results in death or myocardial infarction in 64.4% of cases, with mortality rates of 20-45%. 1, 3 This catastrophic complication risk applies to both BMS and DES, though the timing differs—late stent thrombosis (beyond 1 month) occurs more frequently with DES at approximately 0.19% annually. 1
Perioperative Management
If urgent surgery is required and dual antiplatelet therapy must be interrupted, aspirin should be continued whenever possible while the P2Y12 inhibitor (clopidogrel) is temporarily held. 1 The P2Y12 inhibitor should be restarted as soon as possible postoperatively. 1 For elective surgery, postponement for 12 months after DES placement is strongly recommended. 1, 3
Dosing Nuances for Bleeding Risk
For patients with bleeding concerns, lower-dose aspirin (75-162 mg daily) can be used even during the initial post-stent period, though the standard recommendation is 162-325 mg for the first 1-6 months depending on stent type. 1 Two major trials demonstrated increased bleeding risk with higher-dose aspirin without clear benefit in preventing stent thrombosis. 1
Evidence Quality
The recommendation for aspirin continuation indefinitely after both BMS and DES placement is supported by Grade 1A evidence for the initial dual antiplatelet period and Grade 1B evidence for transitioning to aspirin monotherapy after 12 months. 1, 2 Extended dual antiplatelet therapy beyond 12 months shows no benefit and possible harm based on merged randomized trial data. 1, 3