Management of Anticoagulation Therapy when Aspirin is Discontinued in Patients with Coronary Stents

General Principles

The European Society of Cardiology recommends that in patients with chronic coronary syndrome (CCS) who have received a coronary stent and do not have an indication for oral anticoagulation therapy, dual antiplatelet therapy (DAPT) consisting of aspirin 75-100mg and clopidogrel 75mg daily for up to 6 months is the default anti-thrombotic strategy after stent placement 1
The European Society of Cardiology recommends that aspirin 75-100mg daily be continued indefinitely in patients who have had a myocardial infarction or have received a coronary stent 2
Clopidogrel 75mg daily is recommended as a safe and effective alternative to aspirin monotherapy 2

After uncomplicated stent placement in patients with CCS who have an indication for oral anticoagulation therapy, aspirin should be discontinued early (≤1 week) and oral anticoagulation therapy (OAC) combined with clopidogrel should be continued 1, 3
The American Heart Association recommends that direct oral anticoagulants (DOACs) be preferred over vitamin K antagonists (VKAs) in eligible patients 1, 4

If aspirin needs to be temporarily discontinued (e.g., for surgery), both the risk of bleeding and the risk of stent thrombosis should be assessed 5, 6
For drug-eluting stents (DES), continuing aspirin during surgery is the preferred option 5
If aspirin must be discontinued due to a high risk of bleeding, aspirin and clopidogrel can be discontinued for 5 days, and low-molecular-weight heparin can be considered as a substitute 5, 6

Time since stent placement: The risk of stent thrombosis is highest in the first 30 days after stent placement 4
Type of stent: Drug-eluting stents have a higher risk of late stent thrombosis than bare-metal stents 7
Risk of bleeding: The risk of bleeding should be carefully assessed for each procedure/surgery 5, 6
Risk of thrombosis: Factors such as complex stents, stents in bifurcations, and a history of stent thrombosis should be evaluated 1

The European Society of Cardiology does not recommend the use of ticagrelor or prasugrel as part of triple anti-thrombotic therapy with aspirin and OAC 1
Proton pump inhibitors should be used in patients with an increased risk of gastrointestinal bleeding during combination anti-thrombotic therapy 1
Non-urgent surgery should be delayed for at least 12 months after coronary stent placement, if possible 7

The American Society of Anesthesiologists recommends that the risk of stent thrombosis is highest when both antiplatelet agents are discontinued simultaneously, particularly in patients with recent stent placement 8
The European Heart Society states that stent thrombosis can be catastrophic, leading to myocardial infarction, cardiogenic shock, and death 9
The American Heart Association suggests that the timing since stent placement is critical - risk is highest within the first 30 days for bare-metal stents and within the first year for drug-eluting stents 10
For drug-eluting stents, the American College of Cardiology recommends that clopidogrel should be continued for at least 3 months for sirolimus-eluting stents and 6 months for paclitaxel-eluting stents, ideally up to 12 months 10
The European Heart Society advises that if both agents must be discontinued, maintain aspirin therapy during the procedure if possible, as this provides some protection against stent thrombosis 8, 11
The American Society of Anesthesiologists recommends limiting the interruption period to the shortest time possible if both agents must be discontinued 11

The American Society of Anesthesiologists suggests that for patients at high risk of thrombosis but requiring temporary discontinuation of oral anticoagulants, transition to shorter-acting drugs such as heparin or low-molecular-weight heparin may be appropriate 8

The European Heart Society states that the patient's desire for "aggressive" treatment of their disease must be balanced against the risk of catastrophic stent thrombosis 11
The European Heart Society recommends that the upcoming cardiology follow-up provides an opportunity for a comprehensive risk assessment by the cardiologist before proceeding with biopsy 9
The American Society of Anesthesiologists advises consulting with the cardiologist immediately to develop a personalized bridging strategy if the biopsy is urgent and cannot be delayed until after the cardiology consultation 8
The European Heart Society suggests maintaining at least one antiplatelet agent (preferably aspirin) during the procedure if the bleeding risk allows 11