You'll get questions about optimizing antithrombotic regimens for patients with a coronary stent...based on evolving evidence.
What’s the ideal duration for dual antiplatelet therapy (DAPT)?
Stick with 12 months of DAPT with aspirin 81 mg/day AND a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) for most acute coronary syndrome (ACS) patients with a stent...then reassess.
Or recommend 6 months of DAPT with aspirin plus clopidogrel for most stable patients who get a drug-eluting stent.
But consider just 1 to 3 months of DAPT for stable or ACS patients with a stent if bleeding risk seems to outweigh thrombotic risk.
Mounting evidence suggests that this may be enough for select patients...such as those with high bleeding risk due to advanced age or prior GI or intracranial bleeding.
In these cases, give DAPT for 1 to 3 months...followed by the P2Y12 inhibitor alone for up to 12 months...then one antiplatelet indefinitely.
Which antiplatelet is preferred long-term after DAPT? The default for years has been aspirin...based on its long track record of CV risk reduction and low cost.
Now recent evidence suggests that using clopidogrel instead of aspirin long-term reduces the risk of CV events and major bleeding.
But it’s too soon to apply these data across the board.
For example, this is an open-label study conducted in South Korea. And it doesn’t provide information on how outcomes varied in “poor metabolizers” with less conversion of clopidogrel to its active form.
Continue to rely on aspirin for most patients. Many patients tolerate it well...plus it’s OTC and costs just pennies a day.
But consider clopidogrel as an option...especially for patients with high bleeding or CV risk. It’s generic and costs about $10/mo.
What’s preferred for patients with atrial fib plus a stent? Expect most of these patients to step down from TRIPLE therapy with a direct oral anticoagulant (DOAC) plus DAPT...to dual therapy with a DOAC and clopidogrel within a month after stent placement.
Then generally suggest stopping clopidogrel one year post-stent...especially in those at higher bleeding risk or low thrombosis risk. Limited evidence suggests that a DOAC alone is often enough at this point.
Get our resource, Dual Antiplatelet Therapy for Coronary Artery Disease, for tools to assess bleeding and thrombotic risk and more.
- Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023 Aug 29;148(9):e9-e119.
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- Medication pricing by Elsevier, accessed Oct 2023.