This is a controversial and unsettled area. We have lots of opinions, but we don’t have good randomized controlled trials to guide therapy. The trials essentially compared 4 vs 12 months and clearly showed a reduction in repeat myocardial infarction for the longer period. So ideally, after angioplasty, patients should remain on aspirin and clopidogrel for 12 months. Unfortunately, we don’t have good data beyond this timeframe. In patients with a drug-eluting stent, and in high-risk angioplasties, many interventional cardiologists are using clopidogrel for 24 months or even longer. It is, however, very expensive.

My advice is to use aspirin and clopidogrel for up to 12 months following acute coronary syndromes and angioplasty. Recently, a trial of clopidogrel following bypass surgery to maintain graft patency showed no advantage over aspirin therapy alone, and it can’t be recommended for this indication.

In patients with recurrent cardiovascular events, multiple, poorly controlled risk factors, and high-risk angioplasty including left main disease, it seems not unreasonable to stay longer on aspirin and clopidogrel — possibly even indefinitely. But antiplatelet therapies, alone or in combination, are potentially dangerous drugs and can lead to hemorrhagic complications.

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