Optimal Management of Patients with Drug-Eluting Stents on Antiplatelet Therapy
Guideline Recommendations
- The American College of Cardiology and European Society of Cardiology recommend an optimal P2Y12 reaction unit (PRU) target range of <208-235 PRU to balance thrombotic and bleeding risk 1, 2
- The European Society of Cardiology does not recommend routine platelet function testing to adjust antiplatelet therapy in patients after stent placement 2
- Guidelines prioritize selecting the appropriate P2Y12 inhibitor based on clinical factors rather than adjusting therapy based on PRU values 1, 2, 3, 4
Preferred P2Y12 Inhibitor Selection
- The European Society of Cardiology recommends ticagrelor (180 mg loading, 90 mg twice daily) as first-line therapy for all ACS patients with drug-eluting stents 2, 5
- Prasugrel (60 mg loading, 10 mg daily) is reasonable for P2Y12 inhibitor-naïve patients undergoing PCI, unless contraindicated by prior stroke/TIA, age ≥75 years, or weight <60 kg 2, 5
- Clopidogrel (600 mg loading, 75 mg daily) should be reserved for patients who cannot receive ticagrelor or prasugrel due to contraindications, prior intracranial bleeding, or need for oral anticoagulation 2, 5
Duration of Therapy
- The American College of Cardiology and European Society of Cardiology recommend continuing DAPT for 12 months in all ACS patients with drug-eluting stents unless excessive bleeding risk exists (e.g., PRECISE-DAPT score ≥25) 2, 4, 5
- Daily aspirin dose should be 75-100 mg (81 mg in US) when combined with any P2Y12 inhibitor 2, 4, 5