What is the purpose and management of a patient on Aspirin (acetylsalicylic acid) 325mg and Plavix (clopidogrel) 75mg dual antiplatelet therapy?

Dual Antiplatelet Therapy: Aspirin 325mg and Clopidogrel 75mg

Primary Indication and Purpose

This combination represents dual antiplatelet therapy (DAPT) primarily indicated for acute coronary syndrome (ACS) or following coronary stent placement, where it reduces death, myocardial infarction, and stroke by inhibiting platelet aggregation through two distinct mechanisms. 1, 2

The aspirin dose of 325mg is higher than the recommended maintenance dose and should typically be reduced to 75-100mg daily for long-term therapy to minimize bleeding risk while maintaining efficacy. 1, 2

Clinical Indications

Acute Coronary Syndrome

• For ACS patients (STEMI or NSTE-ACS), DAPT with aspirin plus clopidogrel is indicated for 12 months unless excessive bleeding risk exists (e.g., PRECISE-DAPT score ≥25). 1
• In ACS, clopidogrel 75mg daily on top of aspirin is recommended when ticagrelor or prasugrel cannot be used, including patients with prior intracranial bleeding or those requiring oral anticoagulation. 1
• The CURE trial demonstrated a 20% relative risk reduction (9.3% vs 11.4%, p<0.001) in cardiovascular death, MI, or stroke with clopidogrel plus aspirin versus aspirin alone in ACS patients. 3

Post-Percutaneous Coronary Intervention (PCI)

• After bare-metal stent placement, DAPT should continue for at least 1 month; after drug-eluting stents, continue for at least 3-6 months (sirolimus) to 12 months, depending on bleeding risk. 1
• For carotid artery stenting (CAS), DAPT with aspirin 81-325mg plus clopidogrel 75mg is recommended for a minimum of 30 days before and after the procedure. 1

Stable Coronary Artery Disease

• DAPT is NOT indicated for stable CAD managed medically without revascularization. 1
• Clopidogrel 75mg daily is recommended only during and after coronary stent implantation in stable CAD patients. 1

Dosing Optimization

Aspirin Dose Adjustment

• The current 325mg aspirin dose should be reduced to 75-100mg daily for maintenance therapy to minimize bleeding complications while preserving antiplatelet efficacy. 1, 2
• Higher aspirin doses (>100mg) increase bleeding risk without additional ischemic benefit. 1

Clopidogrel Maintenance

• The 75mg daily dose is appropriate for maintenance therapy. 1, 3
• Loading doses (300-600mg) are only needed at initiation in ACS or before PCI, not for ongoing therapy. 2, 4

Duration of Therapy

Standard Duration

• 12 months of DAPT is the standard recommendation for ACS patients, whether managed medically or with PCI. 1
• After 12 months, continuation beyond this period may be considered if no bleeding or tolerability issues occur, though this should be weighed against bleeding risk. 1

Early Discontinuation Considerations

• Do not discontinue DAPT within the first month after stent placement, even for elective non-cardiac surgery. 1
• For urgent surgery requiring clopidogrel discontinuation, stop at least 5 days before the procedure while continuing aspirin if bleeding risk allows. 1, 2

Bleeding Risk Management

Proton Pump Inhibitor Co-Administration

• A PPI in combination with DAPT is recommended to reduce gastrointestinal bleeding risk. 1
• Avoid omeprazole and esomeprazole specifically, as they significantly reduce clopidogrel's antiplatelet activity; dexlansoprazole, lansoprazole, or pantoprazole are preferred alternatives. 3

Monitoring for Bleeding

• Patients will bruise and bleed more easily and take longer to stop bleeding. 3
• Any unanticipated, prolonged, or excessive bleeding, or blood in stool or urine, requires prompt medical evaluation. 3

Considerations for Switching P2Y12 Inhibitors

When to Consider Alternatives

• In ACS patients, ticagrelor (180mg loading, 90mg twice daily) or prasugrel (60mg loading, 10mg daily) are preferred over clopidogrel due to superior reduction in major adverse cardiovascular events and stent thrombosis. 1, 2
• Clopidogrel remains appropriate when ticagrelor or prasugrel are contraindicated (prior intracranial bleeding, age >75 years for prasugrel, need for oral anticoagulation). 1

Switching Protocol

• When switching from clopidogrel to ticagrelor in ACS patients, administer ticagrelor 180mg loading dose early after hospital admission, regardless of clopidogrel timing or dose. 1

Common Pitfalls to Avoid

• Never discontinue both antiplatelet agents simultaneously in the first 12 months post-ACS or post-stent without cardiology consultation, as this dramatically increases thrombotic risk. 1, 5
• Do not use routine platelet function testing to adjust therapy before or after elective stenting—it is not recommended and lacks evidence for improved outcomes. 1
• Avoid NSAIDs (both nonselective and COX-2 selective) in patients with acute or previous STEMI due to increased mortality, reinfarction, and heart failure risk. 1
• For radial access during coronary procedures, this approach is recommended over femoral access when performed by an expert operator to minimize bleeding complications. 1