Antiplatelet therapy after ACS or PCI

Antiplatelet therapy after acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) and in patients requiring surgery

Antiplatelet therapy after PCI (otherwise known as “stenting”)

Patients following ACS or PCI are usually recommended to have 6 months of dual antiplatelet therapy (DAPT) consisting of aspirin in addition to another agent (clopidogrel, ticagrelor or prasugrel). There are circumstances where the duration of DAPT differs such as taking part in a clinical trial or when extended dual therapy is recommended in those patients at high risk of stent complications who have low bleeding risk. The choice of antiplatelet regimen should take the bleeding risk of the patient into account. Shorter durations of DAPT can be used in some circumstances but please consult with the cardiology team.

Antiplatelet therapy after PCI in patients who have an indication for formal oral anticoagulation (OAC)

In patients who have ACS and no PCI it is common to give 6 months of single antiplatelet therapy (usually clopidogrel) in addition to their usual oral anticoagulant. In patients who receive PCI it is common to give a short period of ‘triple therapy’ (OAC+DAPT) for one week or one month followed by OAC + single antiplatelet for 6-12 months followed by OAC alone. In patients at highest bleeding risk ‘triple therapy’ may be avoided completely; these patients are often prescribed DAPT (no OAC) for a short period before switching to OAC and single antiplatelet and finally stepping down to OAC alone later.

Patients who have historic coronary stents usually maintained on OAC alone (for other reasons) who no longer require OAC therapy should be restarted on single antiplatelet therapy.

Patients after ACS or PCI requiring surgery

Early discussion with Cardiology is encouraged where patients with a recent ACS or coronary stents require surgery. For any coronary stent, the preference is to continue a single antiplatelet peri-operatively. For patients taking dual antiplatelet therapy, or who have a stent placed within 12 months, please discuss with cardiology to agree a management plan.

N.B. If there is any doubt surrounding anticoagulation/ antiplatelet regimes after ACS/ PCI or in patients following ACS or who have coronary stents requiring surgery, please seek advice from the Cardiology team.