In a typical adult undergoing carotid endarterectomy, should dual antiplatelet therapy be used?

Antiplatelet Therapy for Carotid Endarterectomy

Single antiplatelet therapy (SAPT) with either aspirin (75-325 mg daily) or clopidogrel (75 mg daily) is the recommended standard for patients undergoing carotid endarterectomy, not dual antiplatelet therapy (DAPT). 1

Primary Recommendation

• The American College of Chest Physicians explicitly recommends SAPT over DAPT for patients after CEA (Grade 2B recommendation). 1
• This applies to both symptomatic and asymptomatic patients undergoing the procedure. 1
• Low-dose aspirin (81-325 mg) should be continued perioperatively and long-term for secondary stroke prevention. 1, 2

Evidence Supporting Single Antiplatelet Therapy

• SAPT reduces stroke risk after CEA with an odds ratio of 0.58 (95% CI 0.34-0.98), translating to 34 fewer strokes per 1,000 patients treated. 1
• Meta-analysis demonstrates that SAPT is associated with lower rates of:
  • 30-day mortality (rate difference 0.002, p=0.014) 3
  • Neck hematoma requiring intervention (OR 2.12 for DAPT vs SAPT, p<0.001) 3
  • Major bleeding (rate difference 0.005, p<0.001) 3
  • Myocardial infarction (rate difference 0.004, p=0.003) 3
• Real-world data shows 66% of patients are appropriately discharged on SAPT following CEA. 4

When DAPT Should NOT Be Used

• Do not extrapolate carotid artery stenting (CAS) guidelines to CEA patients—the thrombotic mechanisms differ. 1
• DAPT increases bleeding complications without reducing ischemic events after CEA. 5, 3
• A large Dutch registry analysis (12,317 patients) found no association between DAPT and reduced stroke/TIA compared to SAPT (OR 0.81,95% CI 0.58-1.13, p=0.23). 5
• Wound hematoma occurs in 24.1% of patients on DAPT versus 11.7% on aspirin alone (relative risk 2.4,95% CI 1.4-4.1). 6

The Only Exception: Symptomatic Carotid Stenosis NOT Undergoing Revascularization

• For symptomatic carotid stenosis patients who are NOT undergoing CEA or stenting, DAPT with aspirin and clopidogrel (75 mg) is recommended for the first 21 days, followed by single antiplatelet therapy. 7
• This recommendation does not apply to patients actually undergoing CEA. 1

Special Circumstances

• If a patient requires DAPT for another indication (e.g., recent coronary stenting), clopidogrel plus aspirin may be continued for up to 1 year post-CEA. 1
• For patients on anticoagulation who undergo CEA, antiplatelet therapy should be stopped and anticoagulation alone continued when safe from bleeding perspective (typically 3-14 days post-surgery). 1
• Aspirin should be restarted within 24 hours post-operatively when hemostasis is achieved. 2

Dosing Specifics

• Low-dose aspirin (81-325 mg) is superior to high-dose aspirin (650-1,300 mg), with lower combined rates of stroke, MI, and death at 30 days (5.4% vs 7.0%). 1
• Avoid aspirin doses above 325 mg—they increase bleeding without additional benefit. 1

Common Pitfalls to Avoid

• Do not stop aspirin before CEA—it should be continued perioperatively. 2
• Do not confuse CAS with CEA protocols—CAS requires DAPT for minimum 30 days, but CEA does not. 1, 8
• Do not discontinue antiplatelet therapy prematurely—long-term SAPT is essential for secondary stroke prevention and should continue indefinitely unless contraindicated. 1
• Do not delay resumption of antiplatelet therapy post-operatively—restart within 24 hours when hemostasis achieved. 2

Contrast with Carotid Artery Stenting

• For CAS specifically, DAPT with aspirin (81-325 mg) plus clopidogrel (75 mg) is required for minimum 30 days (Class I, Level C recommendation). 1, 8
• This fundamental difference reflects distinct thrombotic mechanisms between stenting and endarterectomy. 1