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New Guidance on Antiplatelet Therapy After Stenting: Clinical Advisory

An expert panel recommends 12 months of therapy after placement of drug-eluting stents.

Aspirin and clopidogrel are commonly prescribed after placement of both bare metal stents and drug-eluting stents. However, recent concerns about stent thrombosis (Journal Watch Jan 4 2007) have led experts from multiple groups, including the American Heart Association and the American College of Cardiology, to issue an advisory on preventing premature discontinuation of dual antiplatelet therapy. Based on a review of the literature, the experts offer observations and recommendations including the following:

• Dual antiplatelet therapy with aspirin and a thienopyridine such as clopidogrel reduces cardiac events after coronary stenting.
  
• Premature discontinuation of these agents greatly increases the risk for stent thrombosis and associated clinical events such as myocardial infarction and death.
  
• Patients should receive 12 months of dual antiplatelet therapy after placement of drug-eluting stents.
  
• Elective surgery associated with a significant risk for bleeding should be postponed until an appropriate course of dual antiplatelet therapy (i.e., 1 month for bare metal stents and 12 months for drug-eluting stents) has been completed.
  
• Patients’ ability to comply with prolonged dual antiplatelet therapy and their need for subsequent invasive procedures should be considered when choosing the type of stent.
  
• Patients and their other providers should consult with the patient's cardiologist before stopping dual therapy.
  

Comment: Although we don’t yet have all the data necessary to gauge the optimal duration of dual antiplatelet therapy after stenting, this advisory provides common-sense guidelines for practitioners based on available data.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine February 15, 2007

Citation(s):

Grines CL et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007 Feb 13; 115:813-8.