A structured review supports long-term low-dose aspirin plus a P2Y12-receptor inhibitor for 1 year.

Dual antiplatelet therapy with long-term, low-dose aspirin (75–100 mg daily) plus a P2Y12-receptor inhibitor (usually clopidogrel) for 1 year after stent placement is the standard recommendation. Although this recommendation applies to both drug-eluting and bare-metal stents, a shorter duration of clopidogrel therapy (minimum of 1 month) is considered to be permissible for patients who have received bare-metal stents for nonacute coronary syndrome indications. Higher doses of aspirin (>200 mg daily) are associated with a twofold higher risk for bleeding, with no additional benefit. Risk for stent thrombosis continues beyond 1 year; however, studies of P2Y12-receptor inhibitor use beyond 1 year show no benefit in the face of elevated bleeding risk. Large clinical trials of shorter and longer durations of P2Y12-receptor inhibition are under way.

COMMENT

Three P2Y12-receptor inhibitors are available. However, adverse events have limited use of prasugrel (Effient) and ticagrelor (Brilinta). Studies of optimal clopidogrel dosing suggest that bleeding risk rises with higher doses; thus, the current recommendation is for a 300-mg loading dose followed by 75 mg daily. Because adding warfarin (i.e., for patients with atrial fibrillation or mechanical heart valves) is associated with two- to threefold higher risk for major bleeding complications, aspirin should be discontinued while patients receive warfarin. If at all possible, noncardiac elective surgery should be delayed until 1 full year of dual antiplatelet therapy with aspirin and clopidogrel is completed. Patients at high risk for bleeding should take proton-pump inhibitors while receiving dual antiplatelet therapy. Based on anticipated studies, clinicians soon might have more guidance for tailoring dual antiplatelet therapy duration to a patient’s specific clinical profile and type of stent.