A 75-year-old man with a previous history of persistent AF, peptic ulceration, and renal failure (creatinine 220 μmol/L) undergoes elective PCI to his LAD with a bare metal stent (BMS). He was on warfarin for AF prior to his PCI.
What is the best combination of drugs immediately following the procedure?
This is a difficult question. This man has a HAS-BLED score of 3 (one point for each of age >65 years, renal failure, and bleeding predisposition), putting him at a high risk of bleeding. However, he also has a significant thromboembolic risk and antiplatelet drugs alone will not protect him from stroke. The ESC guidelines suggest that, ideally, he should have a BMS rather than a drug-eluting stent to reduce the duration of dual antiplatelets, but he will still require a minimum of 28 days triple therapy (2.6–4.6% risk of major bleed at 30 days). However, data now available for newer-generation drug-eluting stents support 3 months DAP only in some cases and so the risk of reintervention/restenosis is also relevant.