Dual Antiplatelet Therapy in Patients with Multivessel Coronary Stent Placement

Introduction to DAPT

The American College of Cardiology recommends that patients with multivessel coronary stent placement should continue dual antiplatelet therapy (DAPT) for at least 12 months, with consideration for extended therapy beyond 12 months in patients who have tolerated DAPT without bleeding complications and are at low bleeding risk but high thrombotic risk 1, 2

For patients with acute coronary syndrome (ACS) treated with drug-eluting stent (DES) or bare metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months, in combination with a daily aspirin dose of 81 mg (range 75-100 mg) 1, 2
Ticagrelor is preferred over clopidogrel (Class IIa, Level B-R) for ACS patients with multivessel stenting 1, 3
Prasugrel is reasonable over clopidogrel in patients without high bleeding risk or history of stroke/TIA (Class IIa, Level B-R) 1, 3

Extended DAPT beyond 12 months may be reasonable (Class IIb) for patients with multivessel stenting who have tolerated DAPT without bleeding complications, are not at high bleeding risk, and have high thrombotic risk factors such as multivessel stent placement, diffuse multivessel disease, or history of STEMI 4

Discontinuation of P2Y12 therapy after 6 months may be reasonable (Class IIb, Level C-LD) for patients who develop high bleeding risk after DES implantation, such as those who require oral anticoagulation therapy or are at high risk of severe bleeding complications 1, 2
Patients with high bleeding risk factors, such as advanced age, oral anticoagulant use, prior bleeding history, or end-stage renal failure, should be managed with caution 4

Use of low-dose aspirin (75-100 mg daily) and consideration of proton pump inhibitors in patients with history of gastrointestinal bleeding or increased risk of bleeding are recommended 3
Regular monitoring for bleeding complications and modifying modifiable risk factors for bleeding are also recommended 3

Prasugrel should never be administered to patients with prior history of stroke or TIA (Class III: Harm) 1