post-procedural management

Last reviewed 01/2018

• post-procedural management of patients with coronary stents is focussed on prevention of stent thrombosis and secondary prevention of the underlying vascular disease
  • risk of stent thrombosis is minimised by treatment with the combination of aspirin and clopidogrel ('dual anti-platelet therapy')
    • biggest risk factor for stent thrombosis is premature discontinuation, or reduction in the intensity of, antiplatelet therapy (i.e before re-endothelialisation is complete)
    • aside from patient compliance, the most frequent reasons for withdrawal of anti-platelet therapy are gastric intolerance or upper gastro-intestinal haemorrhage and elective or urgent major surgery
      • since the signalling pathways blocked by both aspirin and clopidogrel are irreversibly inhibited for the life of the platelet, stent thrombosis is typically delayed for several days after the withdrawal of therapy
      • gastric intolerance to aspirin or clopidogrel (or both) can usually be suppressed by use of a proton-pump inhibitor (PPI). Patients over 75 years of age or with a past history of peptic ulceration, gastritis or oesophagitis should be considered for concomitant prescription of a PPI in prophylactic dosage
      • surgery following PCI
        • many surgical procedures, including tooth extraction, can be undertaken safely during continued anti platelet treatment.However, all forms of surgery should, if possible, be delayed for a minimum of one month after implantation of a bare metal stent and for six months after a drug eluting stent
        • when emergency surgery is required and bleeding risk is low or moderate, it is safest to continue with one or both agents
          • if antiplatelet treatment has to be withdrawn for surgery or haemorrhage, it should be resumed as soon it is safe to do so

For secondary prevention, in the absence of intolerance, all patients should, in keeping with current guidelines, receive aspirin, a statin and an angiotensin converting enzyme inhibitor; those who have had a myocardial infarction will usually also be taking a beta-blocker.

Reference:

• (1) British Heart Foundation Factfile (May 2008). Managing patients with coronary stents.