Management of Coronary Artery Disease with Drug-Eluting Stents

Dual Antiplatelet Therapy (DAPT) Recommendations

• The American College of Cardiology recommends that patients with coronary artery disease who have received a drug-eluting stent should receive dual antiplatelet therapy with aspirin and a P2Y12 inhibitor for at least 12 months to reduce the risk of stent thrombosis, myocardial infarction, and death 1, 2, 3
• The American Heart Association suggests that DAPT consists of low-dose aspirin plus a P2Y12 inhibitor, such as clopidogrel, prasugrel, or ticagrelor, for patients with acute coronary syndrome treated with drug-eluting stents 3, 4
• For patients with acute coronary syndrome treated with drug-eluting stents, the American College of Cardiology recommends using ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy 4, 5

Extended DAPT Considerations

• The American College of Cardiology suggests that in patients who have tolerated DAPT for 12 months without bleeding complications and are not at high bleeding risk, continuation of DAPT beyond 12 months may be reasonable 3, 4, 6
• The decision to extend DAPT should be based on a careful assessment of the benefit/risk ratio, weighing ischemic risk against bleeding risk, according to the American Heart Association 3, 6

Management of Perioperative Period

• The American College of Cardiology recommends that elective surgery should be postponed for 12 months after drug-eluting stent placement if possible 1, 2, 8
• The American Heart Association suggests that if surgery cannot be deferred, aspirin should be continued during the perioperative period in high-risk patients with drug-eluting stents 1, 2

Risks of Premature DAPT Discontinuation

• The American College of Cardiology states that premature discontinuation of DAPT is the leading independent predictor for stent thrombosis, with mortality rates of 20-45% 1, 2, 9
• The American Heart Association reports that stent thrombosis occurs in up to 29% of cases in patients who prematurely discontinue DAPT 9

Long-Term Management Beyond DAPT

• The American College of Cardiology recommends that after completion of the recommended DAPT duration, aspirin therapy should be continued indefinitely in patients with coronary artery disease 3, 4
• The American Heart Association identifies risk factors for stent thrombosis, including small vessels, multiple lesions, long stents, overlapping stents, ostial or bifurcation lesions, suboptimal stent results, low ejection fraction, advanced age, diabetes mellitus, renal failure, and acute coronary syndrome 1, 2, 9

Special Considerations

• The American Heart Association recommends that for patients requiring triple therapy, the duration of triple therapy should be kept as short as possible 5, 7
• The American College of Cardiology suggests that in patients on triple therapy, clopidogrel is the P2Y12 inhibitor of choice 5, 7
• The American Heart Association states that newer-generation drug-eluting stents have improved safety profiles and lower risk of stent thrombosis compared to first-generation drug-eluting stents 3, 6
• The American College of Cardiology recommends that prasugrel should not be administered to patients with a prior history of stroke or TIA 4, 5