A 62-year-old gentleman presents to the outpatient office for a regular follow-up visit. He suffered an acute inferior wall myocardial infarction 11 months ago, requiring stenting of his mid-right coronary artery with an everolimus-eluting stent. He had mild nonobstructive coronary artery disease in the left circumflex and left anterior descending arteries. He smoked half a pack of cigarettes per day for 20 years and quit smoking after the myocardial infarction. He is overweight (body mass index of 28 kg/m2) and is being managed medically for diabetes, hypertension, and dyslipidemia. He also has a history of left lower extremity intermittent claudication with an ankle-brachial index of 0.70 and is managed with pharmacotherapy and a supervised exercise program. His medications include aspirin 81 mg daily, clopidogrel 75 mg daily, atorvastatin 80 mg daily, lisinopril 20 mg daily, carvedilol 25 mg twice daily, pantoprazole 40 mg daily, and metformin 500 mg twice daily. His blood pressure today is 122/68 mmHg with a pulse of 62 bpm. His physical examination is otherwise unremarkable. He denies any chest pain, palpitations, or shortness of breath. His echocardiogram done 3 months ago demonstrates inferior wall akinesis with a left ventricular ejection fraction of 55%. His echocardiogram demonstrates sinus rhythm with Q waves in leads II, III, and aVF. His hemoglobin A1c is 7.5%, and low-density lipoprotein is 68 mg/dl. He feels well, goes for weekly salsa classes with his wife, and is able to walk 3-4 city blocks without any claudication, chest discomfort, or dyspnea.
He was told by his primary care doctor that he can stop his clopidogrel 12 months after the stent implantation.
The correct answer is: D. Discuss the benefits and risks of extended antiplatelet therapy and recommend prolonged dual antiplatelet therapy (DAPT) to reduce ischemic events.
In the recently published DAPT Study (Dual Antiplatelet Therapy Study), longer duration of DAPT was associated with reduced risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events.1 Longer duration of DAPT, however, is associated with increased bleeding, and a risk benefit assessment should be ascertained prior to recommending extended DAPT. This patient has tolerated DAPT for 11 months without any bleeding complications. Therefore, there is no contraindication to continue clopidogrel. So answer A is incorrect. The WAVE (Warfarin Antiplatelet Vascular Evaluation) trial assessed the role of oral anticoagulant plus antiplatelet therapy versus antiplatelet therapy alone for reduction of cardiovascular events in patients with peripheral arterial disease. The trial demonstrated no differences in cardiovascular outcomes but a 3.4-times-higher risk of bleeding complications in the oral anticoagulant plus antiplatelet group.2 Adding an oral anticoagulant would be a Class III recommendation, thus answer B is incorrect.3 Noninvasive testing in an asymptomatic patient with recent (complete) revascularization is not indicated and rarely appropriate. If the patient remains asymptomatic 2 years after percutaneous coronary intervention, stress radionuclide imaging, stress echocardiography, or stress cardiac magnetic resonance imaging may be appropriate. Therefore, answer C is incorrect.
Answer D is correct because the patient has atherosclerosis of multiple vascular beds, which places him at higher risk of ischemic events. Recent data from the subgroup analysis of PRODIGY (Prolonging Dual-Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia Study) suggest benefits of prolonged DAPT in patients with peripheral arterial disease and coronary artery disease without increased risks of bleeding.4
- Mauri L, Kereiakes DJ, Yeh RW, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med 2014;371:2155-66.
- Anand S, Yusuf S, Xie C, et al. Oral anticoagulant and antiplatelet therapy and peripheral arterial disease. N Engl J Med 2007;357:217-27.
- Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011;124:2020-45.
- Franzone A, Piccolo R, Gargiulo G, et al. Prolonged vs Short Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With or Without Peripheral Arterial Disease: A Subgroup Analysis of the PRODIGY Randomized Clinical Trial. JAMA Cardiol 2016;1:795-803.