What is the recommended follow-up care for a patient after stent placement in a family medicine clinic?

Post-Stent Placement Follow-Up in Family Medicine

All patients who have received coronary stents must be maintained on dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor for 12 months, followed by lifelong aspirin monotherapy. 1

Immediate Antiplatelet Therapy Regimen

Core DAPT Protocol

• Aspirin 75-162 mg daily: Start immediately post-procedure and continue indefinitely 2, 1
• P2Y12 inhibitor: Choose one of the following for 12 months 2, 1:
  • Clopidogrel 75 mg daily (most common)
  • Ticagrelor 90 mg twice daily
  • Prasugrel 10 mg daily

Critical Timing Based on Stent Type

The duration of DAPT varies significantly by stent type, and early discontinuation is catastrophic:

• Bare metal stents (BMS): Minimum 1 month DAPT, but 12 months recommended for optimal outcomes 2, 1
• Drug-eluting stents (DES): Mandatory 12 months DAPT due to delayed endothelialization 2, 1
• Early discontinuation within 6 months carries a hazard ratio of 13.74 for stent thrombosis with 45% case fatality rate 1

High Bleeding Risk Modifications

• If bleeding risk outweighs ischemic benefit, discontinue DAPT at 1-3 months and continue single antiplatelet therapy 1
• Add proton pump inhibitor for gastrointestinal bleeding prevention during combined antithrombotic therapy 1

Long-Term Maintenance (After 12 Months)

• Aspirin 75-100 mg daily indefinitely after completing DAPT 1
• Clopidogrel 75 mg daily is acceptable alternative if aspirin not tolerated 1

Clinical Follow-Up Schedule

Immediate Post-Procedure Period

• Monitor for recurrent chest pain and ischemic symptoms 3
• Assess catheter insertion site for bleeding complications 3
• Functional stress testing within days to weeks after discharge provides reassurance about exercise capacity 3

Surveillance Intervals

• First 3 months: Initial catheter-based angiographic follow-up recommended, especially for high-risk lesions 3
• 6 months: Angiographic surveillance for patients who underwent revascularization 2
• 12 months and beyond: Yearly assessment of cardiovascular risk factors and medication adherence 1
• Annual angiographic intervals with noninvasive stress testing for symptomatic patients 3

High-Risk Features Requiring Rigorous 3-Month Surveillance

• Multiple or long stents 4
• Stents at bifurcations 4
• Diabetes mellitus 4, 3
• Low ejection fraction 4
• History of prior stent thrombosis 4
• Incomplete revascularization 4
• LAD lesion location 3
• Hypertension or unstable angina 3

Secondary Prevention Measures

Lipid Management

• High-intensity statin therapy targeting LDL-C <55 mg/dL (<1.4 mmol/L) with ≥50% reduction from baseline 1
• Add ezetimibe if LDL-C goal not achieved with maximum tolerated statin dose 1

Lifestyle Modifications

• 150-300 minutes/week moderate-intensity aerobic exercise 1
• Cardiac rehabilitation program participation strongly recommended 1
• Weight management targeting BMI 18.5-24.9 kg/m² 2
• Waist circumference <35 inches (women) or <40 inches (men) 2

Additional Risk Factor Control

• ACE inhibitors: Start and continue indefinitely in all patients with LVEF ≤40%, hypertension, diabetes, or chronic kidney disease 2
• Beta-blockers: Continue indefinitely in all patients post-MI, acute coronary syndrome, or left ventricular dysfunction 2
• Diabetes management: Target near-normal HbA1c with vigorous modification of other risk factors 2
• Annual influenza vaccination 2

Special Situations

Patients Requiring Oral Anticoagulation

• For chronic coronary syndrome with atrial fibrillation: Use DOAC or VKA at therapeutic dose alone 1
• After PCI with OAC indication: Start low-dose aspirin + clopidogrel + OAC initially, then stop aspirin within ≤1 week post-PCI 1
• Never use ticagrelor or prasugrel with triple therapy due to excessive bleeding risk 1

Mesenteric Artery Stenting

• Clopidogrel for 6 months plus lifelong acetylsalicylic acid 2
• Most patients with underlying hypercoagulability require lifelong anticoagulation 2
• Surveillance imaging via CTA or duplex ultrasound within 6 months, then at 1,6, and 12 months, then annually 2

Critical Pitfalls to Avoid

Never discontinue antiplatelet therapy without cardiology consultation, especially within the first 12 months—this is the strongest predictor of catastrophic stent thrombosis 1, 4. If elective surgery is needed, defer until completion of 12 months DAPT for drug-eluting stents 4. Between 6 weeks and 12 months post-stent, aspirin should be continued and clopidogrel may be stopped 5-7 days before surgery if absolutely necessary, then restarted immediately postoperatively 4.

Monitor closely for medication adherence at every visit, as non-compliance is a major cause of adverse events 1. Assess for bleeding complications, especially during DAPT period, and adjust therapy accordingly 1.