ACC/AHA guidelines: Stents

Definitions

1. Acute Coronary Syndrome (ACS) – A spectrum of conditions that are consistent with myocardial ischemia/infarction, most often due to an abrupt reduction in coronary blood flow. It also refers to patients with symptoms consistent with partial or total blockage of a coronary artery. ACS includes:

a. STEMI – ST elevation MI

b. NSTEMI- Non-ST elevation MI

c. UA- unstable angina

2. Stable Ischemic Heart Disease (SIHD) – People with a history of ACS who have been without recurrent symptoms for > 1 year.

3. Dual Antiplatelet Therapy (DAPT) – Combination therapy consisting of Aspirin and a P2Y12 receptor inhibitor (clopidogrel, ticagrelor, prasugrel) to prevent stent thrombosis, major adverse cardiac events and ultimately reduce mortality rate

Guidelines for Duration of DAPT Following Stent Placement

A. ACS

a. Continue DAPT with aspirin and P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) for at least 12 months after PCI (DES or BMS). Treatment for greater than 12 months may be reasonable if there are no serious signs of bleeding.

B. SIHD

a. Bare Metal Stent (BMS) – Continue DAPT (aspirin and clopidogrel only) for at least 1 month following PCI

b. Drug Eluting Stent (DES) – Continue DAPT for at least 6 months following PCI

Perioperative Management of DAPT Following Stent Placement

A. Elective Surgery

a. BMS – Should be delayed 30 days following PCI

b. DES – Should be delayed 6 months following stent placement

i. If risk of delaying surgery is greater than risk of stent thrombosis, elective surgery can be performed as early as 3 months following PCI

B. Required (Urgent/Emergent) Surgery

a. The risk-benefit of stopping P2Y12 inhibitor should be discussed by the surgical team, cardiology, and anesthesia to weigh the risks of bleeding during surgery vs the risk of cardiac event occurring without DAPT

b. If P2Y12 inhibitor is discontinued, it is recommended aspirin be continued throughout the perioperative period and P2Y12 inhibitor restarted as soon as possible