What is the minimum number of days to hold Dual Antiplatelet Therapy (DAPT) post stent placement for an urgent procedure?

From the Guidelines

The minimum duration of dual antiplatelet therapy (DAPT) after coronary stent placement before an urgent procedure should be at least 1 month for bare metal stents (BMS) and 3-6 months for new-generation drug-eluting stents (DES), but may be acceptable for a minimum of 1 (BMS) to 3 (new-generation DES) months in cases where surgery cannot be delayed for a longer period, as recommended by the 2014 ESC/ESA guidelines 1. When considering an urgent procedure, the risk of stent thrombosis must be weighed against the risk of bleeding.

• For patients with BMS, DAPT can be held for at least 1 month after stent implantation, but a minimum of 1 month of DAPT might be acceptable in urgent cases, as stated in the guidelines 1.
• For patients with new-generation DES, DAPT should be administered for at least 6 months after stent implantation, but a minimum of 3 months of DAPT might be acceptable in urgent cases, according to the guidelines 1.
• In cases where surgery cannot be delayed, the guidelines recommend withholding clopidogrel and ticagrelor for five days and prasugrel for seven days prior to surgery unless there is a high risk of thrombosis, as mentioned in the guidelines 1. It is essential to consider the individual patient's risk factors and the type of stent used when making decisions about DAPT duration and interruption.
• The decision to interrupt DAPT should always balance the thrombotic risk against bleeding risk, with the safest approach being to delay elective procedures until the minimum DAPT duration has been completed.
• When DAPT must be interrupted, aspirin (81mg daily) should typically be continued if possible, with only the P2Y12 inhibitor being held, as a general principle in clinical practice.
• Bridging with short-acting intravenous antiplatelet agents like cangrelor may be considered in extremely high-risk patients, as mentioned in the guidelines 1.

From the Research

Minimum Days to Hold DAPT Post Stent for Urgent Procedure

• The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) has been extensively explored in multiple randomized controlled trials 2, 3, 4, 5.
• For patients undergoing urgent or emergent surgeries, the decision to hold DAPT should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic and bleeding risks 2.
• In cases where surgery cannot be delayed beyond the recommended period after PCI, proceeding to surgery with continued DAPT should be considered 2.
• The recommended interval for elective surgery after drug-eluting stent (DES) implantation has been shortened to 6 months, and in some cases, 3 months if surgery cannot be further delayed 2.
• For intracranial procedures or other selected surgeries with increased bleeding risk, cessation of DAPT with bridge therapy using short-acting, reversible intravenous antiplatelet agents may be contemplated 2, 6.
• A novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery, has been proposed for patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement 6.

Specific Recommendations

• For patients at high bleeding risk, shorter duration (3-6 months) of DAPT may be reasonable 4.
• For patients with continued ischemic risk factors and a low bleeding risk, extended-duration DAPT (up to 30 months) is recommended 5.
• The PRECISE DAPT and DAPT prediction tools can be helpful in making individualized patient treatment decisions 5.