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July 10, 2013

Medical Management After Coronary Stent ImplantationA Review

Author Affiliations
  • 1VA North Texas Health Care System and University of Texas Southwestern Medical Center at Dallas
JAMA. 2013;310(2):189-198. doi:10.1001/jama.2013.7086

Importance  Percutaneous coronary intervention (PCI) with stents is currently the most commonly performed coronary revascularization procedure; hence, optimizing post-PCI outcomes is important for all physicians treating such patients.

Objective  To review the contemporary literature on optimal medical therapy after PCI.

Evidence Review  We performed a comprehensive search of the PubMed and Cochrane Library databases for manuscripts on medical therapy after PCI, published between 2000 and February 2013. Bibliographies of the retrieved studies were searched by hand for other relevant studies. Priority was given to data from large randomized controlled trials, systematic reviews, and meta-analyses. Of the 6852 publications retrieved, 91 were included.

Findings  Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (eg, ticlopidine, clopidogrel, prasugrel, ticagrelor) reduces the risk of stent thrombosis and subsequent cardiovascular events post-PCI (number needed to treat, 33-53) and is the current standard of care. Aspirin should be continued indefinitely and low dose (75-100 mg daily) is preferred over higher doses. A P2Y12 inhibitor should be administered for 12 months after PCI, unless the patient is at high risk for bleeding; however, ongoing studies are assessing the value of shorter or longer duration of P2Y12 inhibitor administration. In patients with acute coronary syndromes, prasugrel and ticagrelor further reduce cardiovascular ischemic events compared with clopidogrel but are associated with higher bleeding risk. If possible, noncardiac surgery should be delayed until 12 months after coronary stenting. Patients receiving coronary stents who require warfarin are at high risk for bleeding if they also receive dual antiplatelet therapy. Omission of aspirin may be advantageous in such patients. Routine platelet function or genetic testing is currently not recommended to tailor antiplatelet therapy after PCI.

Conclusions and Relevance  Dual antiplatelet therapy remains the cornerstone of medical therapy after PCI. Continuous advances in pharmacotherapy can further enhance our capacity to improve outcomes in this high-risk patient group.