Antiplatelet and Statin Therapy in Ischemic Heart Disease
Antiplatelet Therapy
Acute Coronary Syndrome (ACS)
For patients with ACS undergoing PCI with stent placement, initiate dual antiplatelet therapy (DAPT) with aspirin plus a potent P2Y12 inhibitor (ticagrelor or prasugrel) for 12 months unless bleeding risk is excessive. 1
Loading and Maintenance Doses:
Aspirin:
Ticagrelor (preferred in ACS):
Prasugrel (particularly effective in STEMI and diabetics):
Clopidogrel (if ticagrelor/prasugrel contraindicated):
Duration Modifications Based on Bleeding Risk:
- High bleeding risk (PRECISE-DAPT score ≥25): Consider stopping P2Y12 inhibitor at 6 months 1
- Low bleeding risk with high ischemic risk: May continue DAPT beyond 12 months 1
- For extended therapy beyond 12 months in post-MI patients with high ischemic risk, ticagrelor 60 mg twice daily may be preferred over clopidogrel or prasugrel 1
Stable Ischemic Heart Disease (Post-PCI with Stent)
After elective PCI with drug-eluting stent in stable CAD, prescribe aspirin plus clopidogrel for at least 6 months, then continue aspirin indefinitely. 2
Dosing for Stable CAD:
Bare-metal stent: Aspirin 162-325 mg daily for ≥1 month, then 75-162 mg indefinitely; clopidogrel 75 mg daily for ≥1 month (preferably up to 12 months) 2
Drug-eluting stent: Aspirin for 3-6 months (depending on stent type) then 75-162 mg indefinitely; clopidogrel 75 mg daily for ≥12 months 2
Chronic Secondary Prevention (>12 Months Post-MI)
For long-term secondary prevention beyond the acute phase, aspirin 75-100 mg daily is recommended as monotherapy. 1
Statin Therapy
High-Intensity Statin Regimen
All patients with clinical ischemic heart disease (ACS, prior MI, stable angina, post-PCI) should receive high-intensity statin therapy initiated within 24 hours of hospitalization for ACS or at diagnosis of chronic IHD. 1, 4
Dosing:
Atorvastatin 80 mg daily (the only high-intensity statin proven to reduce death and ischemic events in ACS) 4
- Can be given as one 80-mg tablet, two 40-mg tablets, or four 20-mg tablets 4
Rosuvastatin 20 mg daily (alternative high-intensity option) 1
Note: Atorvastatin 40 mg is considered moderate-intensity and does NOT meet high-intensity criteria 1, 4
Evidence Base:
The PROVE-IT TIMI 22 trial demonstrated that atorvastatin 80 mg reduced major cardiovascular events by 16% compared to moderate-intensity therapy in ACS patients, with benefits appearing as early as 30 days 4
Age-Specific Considerations:
≤75 years with clinical ASCVD: High-intensity statin (atorvastatin 80 mg or rosuvastatin 20 mg) 1
>75 years with clinical ASCVD: Moderate-intensity statin should be considered, though high-intensity may be used based on individual assessment 1
LDL-C Targets and Add-On Therapy:
Primary goal: LDL-C <55 mg/dL 4
If LDL-C 55-69 mg/dL on maximally tolerated statin: Consider adding ezetimibe or PCSK9 inhibitor 4
If LDL-C ≥70 mg/dL despite high-intensity statin: Add non-statin lipid-lowering agent 4
Critical Pitfalls to Avoid
Never discontinue statins during ACS hospitalization—abrupt cessation increases short-term mortality 4
Premature discontinuation of DAPT is the strongest predictor of stent thrombosis, which carries up to 20% mortality 5
Do not use simvastatin 80 mg due to increased myopathy risk 1
Monitor for myopathy: Creatine kinase elevations >10× upper limit of normal with muscle symptoms occur more frequently with high-intensity statins 4
Avoid omeprazole and esomeprazole with clopidogrel—they inhibit CYP2C19 and reduce clopidogrel effectiveness; use pantoprazole or lansoprazole instead 5
For patients requiring oral anticoagulation (e.g., atrial fibrillation): Limit triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) to ≤1 month, then transition to dual therapy (P2Y12 inhibitor + anticoagulant) for up to 6 months, followed by anticoagulant alone 1