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Advisory: Premature Discontinuation of Dual Antiplatelet Therapy After Stenting

Experts from five major professional societies recommend dual antiplatelet therapy for 1 year after drug-eluting stent implantation.

Sponsoring Organizations: American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association

After bare-metal or drug-eluting stent (BMS, DES) implantation, dual antiplatelet therapy (aspirin plus a thienopyridine, such as clopidogrel) markedly reduces the risk for adverse events due to stent thrombosis, compared with aspirin alone or warfarin. Experts from five major professional societies now give their advice about dual antiplatelet therapy after stenting.

Among the important points in the advisory are:

• The average reported rate of subacute stent thrombosis with dual antiplatelet therapy is about 1%. However, with DES specifically, the rate may be higher and the onset later, particularly in high-risk lesions (Journal Watch Cardiology Dec 20 2006).
  
• The experts recommend dual antiplatelet therapy for 12 months after DES implantation in patients who are not at high risk for bleeding. This duration exceeds that recommended in manufacturer instructions. (The recommended duration of therapy after BMS implantation remains 1 month.)
  
• Premature discontinuation of dual antiplatelet therapy, particularly within the first year after DES implantation, is associated with a marked increase in the risk for stent thrombosis. This excess risk might extend beyond 1 year (Journal Watch Cardiology Dec 5 2006).
  
• Noncardiac surgery may further increase the risk for stent thrombosis in patients who have discontinued dual antiplatelet therapy (e.g., Journal Watch Cardiology Jun 2 2000).
  
• Factors that contribute to discontinuation of dual antiplatelet therapy include drug cost, insufficient patient education, actual bleeding events, and concerns about excessive bleeding associated with procedures. Such concerns are sometimes misguided (e.g., in the case of minor dental procedures) and sometimes worth debating (e.g., in the case of major surgery).
  
• Both patients and their healthcare providers must be made aware of the risks from discontinuing thienopyridine therapy prematurely and should consider postponing elective procedures with significant bleeding risk for 1 month after BMS implantation and for 12 months after DES implantation.
  

Comment: Dual antiplatelet therapy is essential to prevent stent thrombosis, particularly after DES implantation. Strongly consider avoiding a DES in patients who cannot take aspirin and a thienopyridine for at least 12 months after stenting, including those likely to require a surgical procedure within this time frame. Healthcare professionals should educate patients and each other about the risks of discontinuing dual antiplatelet therapy prematurely; about the need for patients to contact their cardiologists before discontinuation; and about identifying optimal, patient-specific treatment strategies before surgical procedures.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology January 31, 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 Jan 15; [Epub ahead of print]. (http://dx.doi.org/10.1161/CIRCULATIONAHA.106.180944)