No one thought it would take quite so long to get this information, but in just a couple hours results from the Dual Antiplatelet Therapy (DAPT) Study will be presented at the American Heart Association Scientific Sessions 2014. The question to be answered: Is there a benefit to extending dual antiplatelet therapy (aspirin plus a thienopyridine, such as clopidogrel/Plavix, prasugrel/Effient, etc.) beyond one year after stenting?
This is a question asked back in 2006, during a special two-day FDA hearing, convened to discuss all known issues with drug-eluting stents and prompted by the “ESC firestorm” over the problems of increased incidence of late stent thrombosis in drug-eluting stents. (See “Problems Resurface with Drug-Eluting Stents” – September 9, 2006.)
Much has changed in the interim: Cordis/J&J which manufactured Cypher, the first FDA-approved drug-eluting stent, is no longer in the coronary stent business; Plavix has gone generic (as clopidogrel) and two new antiplatelet drugs have come to market: Effient (prasugrel) and Brilinta (ticagrelor); and new second and third generation stents from Abbott (Xience), Medtronic (Resolute) and Boston Scientific (Promus) have replaced the earlier Cypher and Taxus. And this afternoon that hanging question from 2006 is about to be answered.
Quick Background on DAPT and Stent Thrombosis
When a stent is implanted in an artery to push open a blockage and act as a scaffold to hold that artery open, blood flow is increased and angina/ischemia is relieved. In the case of an acute event, such as a heart attack, revascularizing the artery actually stops the infarction, limiting damage to the heart muscle. This “gold standard” treatment for MI has significantly decreased mortality and morbidity for heart attack victims.
But the body sees the metallic stent as an intruder and the blood tries to form a clot. So antiplatelet medications are administered until a layer of endothelial cells literally covers the metallic stent struts, masking the stent from the immune system. When bare metal stents started being used in the 90s, it was thought that this healing process took 4-6 weeks. Although bare metal stents were a major advance over balloon angioplasty, a new disease came about: in-stent restenosis – too much “healing” tissue grew inside the stent and the artery reblocked. In the next decade, drug-eluting stents (DES) became available. The bare metal stent was coated with a special plastic polymer which eluted a drug that slowed down the tissue growth inside the stent. Restenosis rates dropped to single digits and a new era in interventional treatment of coronary artery disease began.
Until 2006, that is, when studies started to show that blood clots inside the stent, called stent thrombosis, were occurring in DES at a higher rate than in bare metal stents, and long after the stent placement. Stent thrombosis and restenosis both result in a blocked or narrowed artery, but they are completely different biological phenomena – and stent thrombosis is most often an acute event: when it occurs, the artery becomes completely blocked very quickly, most often resulting in a heart attack and 1/3 of the time death. To be sure, the percentage of stent thrombosis was small – so small that this signal was not picked up in the 1,000 patient DES clinical trials upon which the FDA based its approvals.
These approvals, by the way, had taken into account the fact that DES slowed down the healing process of tissue growth, so the recommendation for DAPT after stenting was increased to 3 months for the Cypher stent and 6 months for the Taxus stent. But these reports of increased stent thrombosis generated a flurry of activity, culminating in the two-day FDA hearing.
On December 7 and 8, there were over 25 presentations given to an SRO crowd of 500, by industry representatives, cardiologists, surgeons, the three major professional cardiology groups. I testified and so did a patient who heard about the hearing through our Patient Forum. For two days from 8:00am on, the panelists listened and asked questions, sometimes probing, sometimes challenging, and they debated among themselves whether to recommend that the FDA attach stronger warnings, change the labels, lengthen the recommended duration of Plavix and aspirin.
The biggest problem was that there was insufficient data on the effect, good and bad, of increasing the duration of DAPT. Antiplatelet medications thin the blood and increase bleeding complications. Would the benefit of lowering late stent thrombosis (a relatively infrequent but potentially lethal complication) be enough to offset bleeding events? None of the pivotal approval trials were powered to test this issue. In fact, Plavix itself was technically not approved for use post-stenting in non-acute patients. I believe it still isn’t. But that’s another story (see my post on this Catch-22).
The conundrum of increasing duration of DAPT faced by the panelists and the cardiology community is best summed up in this exchange between panelist Dr. Chris White of the Ochsner Clinic and chairperson Dr. William Maisel:
DR. WHITE: I’m loath to change the recommendations that were made without evidence, compelling evidence to make us change. I’m also not sure that continuing Plavix to a year would have any benefit on the…thrombosis that occurs at two, three and four years. So…unless there was some evidence that using [anti] platelet therapy longer than originally had been recommended, the three to six months, that there’s some obvious benefit to that, and knowing that there is risk to that, I think we really shouldn’t be stampeded into making that kind of an emotional decision without evidence….
CHAIRMAN MAISEL: Dr. White, if you had a drug-eluting stent and no increased bleeding risk how long would you take dual anti-platelet therapy?
DR. WHITE: Indefinitely.
CHAIRMAN MAISEL: Me, too!
Laughter rippled throughout the room partially to relieve the tension, but mainly because Dr. White had put his finger on the issue. Dr. Maisel then queried guest panelist Dr. Eric Topol:
DR. TOPOL: Well, just to, I think, go along with Dr. White on this, we did a trial CREDO which actually is the only trial after stenting to look at 30 days to one year. And interestingly that showed, that was in the bare metal stent era, it showed there was, indeed, protection from major events. But interestingly they weren’t stent related. They were non-target vessel events and strokes because of the atherosclerotic underlying disease. So that confirmed a benefit in bare metal stents out to one year. There haven’t been any other trials outside of that one, so to make any kind of sweeping recommendation without data and trying to actually direct the recommendation towards stent thrombosis would be on uncertain grounds.
Current Recommendations, Newer Stents
As a result of this hearing, U.S. guidelines were changed to what they are today: at least one year of DAPT; an extended period is an option for patients who are at high risk for thrombotic events and who are not at risk for bleeding complications. European guidelines were extended as well, but not as much, to 6-12 months.
Also as a result of the issues presented at the hearing, DES usage in the U.S. dropped from 90% to 58% in a matter of months. Bare metal stents were viewed as safer.
Representatives of Abbott Vascular and Medtronic also presented at the FDA hearing: new second generation stent trials that were being conducted not in 1,000 patients, but 5,000, with longer term follow-up to five years. The panelists liked this. And within a few years, these new stents found their way into the marketplace, demonstrating greater efficacy and safety. And DES usage is back to much higher levels.
More recent studies have shown a significantly reduced incidence of late stent thrombosis. This may be due to thinner struts and more biocompatible polymers. Several studies have also been conducted to measure whether a duration of less than a year is safe. An analysis of Medtronic’s RESOLUTE program of 5,000 patients even showed no stent thrombosis increase for patients who needed to stop DAPT after one month! Because of these newer, better devices, the trend has been toward thinking of shorter rather than longer DAPT. After all, DAPT can be expensive. Even generic clopidogrel is running at $4/day. And patients may need surgery, requiring at least a temporary interruption of antiplatelet meds.
So it is with this background that we anticipate the findings of the 10,000 patient DAPT Trial this afternoon to answer the question: “Is longer better?!”
126 Responses to Plavix and Aspirin After Stent: 8 Years Later – Is Longer Better?
My cardiologists suggested I read about the DAPT trials in regards to Plavix-aspirin therapy and the length of therapy. I had 2 des, which are first generation, 15 months ago. Apparently the study ran 30 months. I am wondering if drug therapy is beneficial after that. I am a 72 yr old active female. I worry about bleeding, particularly bleeding in the brain. Some reports on this issue are confusing.
Barbara – You wrote “some reports are confusing” and you couldn’t be more correct. Our report on the recent very large DAPT trial can be found here: “DAPT Study: Extended Treatment After Stenting Lowers Stent Thrombosis and Heart Attacks”. There are nuances to the data and on the face of it, 30 months seemed better than 12, but the important paragraph of the article is here:
So it’s a judgement call as to your relative risk of stent thrombosis vs. bleeding complications and you should discuss these issues with your cardiologist. There is also a seeming benefit to taking clopidogrel, regardless of stents. We’re a bit surprised that you received 1st generation stents as recently as 15 months ago because the newer stents have been on the market for a while now. Do you know the specific name and size of the stents you received (you should have gotten a card with this information)?
So what are the findings? Did you have a blog post about them?
Hi Barbara, I am quite active. I have had two MIs and a pace-maker for years. I have three stents, two bare metal and one DES. I got my third yesterday – a bare metal stent. My second DES had me on plavix for 6 months. The bleeding and itching side effects were most unpleasant. On Brillanta for a while I gasped for breaths.There is “confusion” because there is a LOT of money to be made by drug companies. The stats, so far, say bare metal stents give you an even chance. Doing only one month on plavix made it a no-brainer for me. I will also never, ever, ever stop, or forget, the daily aspirin.
64 year old male here.
I am almost 80 years 22 years ago i had a very bad heart attack, on the er table could not get heart to beat for any time,forgot to run my son out while working on me 2hr of procall er dr said bag him for morge. I could not see but could hear,when nurse pulled bag out of my mouth i said i not dead,Dr said who said that nurse said pacient,he said get on him again and a cardi Dr came in and put pace maker on it started beating.A large part of my left heare was damaged, they cath me 3 days later put in 2 stents .Spent a week there. dr put me on asprin and tenorman.Spent last 22 years doing anything i wanted also 2 pack a day smoking.In dec 2015 started geting short of breath found copd also heart dr checked did a cath found 3 blockages in r side of heart. put in the new stents put me on plavix and asprin. now thay say left side of heart is in failure due to problem 22 years ago 50% also lungs are 50% due to me cont. smoking .Now i cant do anything get short of air just walking across yard. o2 at night and part of dayToday i started iching think it is plavix also bruseing bad for no reason hands and arms having breathing problems. my bp is 130 over 60 heart rate is 60 to 80 sugar is 110 02 level is 94 siting with 02 it goes to 97 but drops to 85 if i walk a lot on treadmill. I was a pilot also drove nascar for a few years. just doing what i can with old army ww2 jeeps . wayne
I’m a 66 y/o man that had 3 DES (Promus) implanted after chest pain brought me to the ER in Nov of 2013. The arteries involved were the RCA, the LDA and the Circumflex. I had never had high blood pressure or elevated lipids. I was told that the blockages were in the 90% range which really surprised me. I was put on Prasugrel and aspirin therapy. I had been under the impression that the prasugrel would be discontinued after 30 months, but now my cardiologist tells me I should keep taking it indefinately. My ejection fraction after the incident has been measured at 58 and 61 on two test. I worry about brain bleeding as well. What about a car accident or a fall on the head? I’m puzzeled about how to weigh the risks versus the benefits given the rather vague big picture.
John – You should discuss this issue with your cardiologist. There are benefits for patients, in some cases, to prolonged antiplatelet therapy above and beyond the issue of preventing blood clots from the stents (which are pretty much resolved at one year).
I have been on Plavix for 20 years after the heart attack. no problems at all. my doctor gets mad every time I ask if its time to get off.
What was your case that you had to take Plavix for 20 years? Did you have any problem related to taking Plavix that long?
My god why are u still taken this I stopped after 3months and I had 3stents. U need to tell your doctor to. Stop lying to you Change doctors for gods sake. I am sure u are having side affects that u don’t even know about. Or u do and think this is normal. I am 54. Have two small grandchildren that live with me and get on with life on my own. Swimming cycling running. But I live in the Netherlands and they would never. Allow u to stay on this medication for this long. Good luck hope u wake up soon and realize that u have been lied to
Joyce – Thanks for your comment. As is stated in this article, and is still a matter of debate today, the proper duration for DAPT (clopidogrel plus aspirin) varies from case to case. As also stated, there are several studies now underway, testing the safety of short-term DAPT 1-3 months, in certain cases! Patients who have had heart attacks, long stent lengths, etc. are typically advised to continue DAPT for a longer period.
As for Oscar, if he’s been on Plavix for 20 years, then it would have been prescribed just after the US FDA approved Plavix in 1997. This was also well before the introduction of drug-eluting stents. The original indications for Plavix were “reduction of atherosclerotic events (myocardial infarction, stroke and vascular death) in patients with atherosclerosis documented by recent stroke, recent MI or established peripheral artery disease.” Its post-stenting use didn’t come into play for a while after that. So Oscar hasn’t been “lied to” but most likely has been prescribed Plavix for reasons other than stents.
My husband has his 1st heart attack 16 years ago. 2 stents one day (4-1/2 hrs of surgery for 2 stents blocked 109 and 98%), back in the table next morning for another long one. Started Plavix. 2 yes later his 4th one,just as his Dr predictive. He has severe heart disease and CAD. Going to get his 9th stent (all have been drug eluded). Estimated every 2-3 yrs another stent. Might have to have bi-pass as he is full on his left side of heart. Has had many Dr said the the combination of Plavix and aspirins have pro- longed a bi-pass…he is now 61 yrs old. Praying for many more yrs
I had 2 DES (Resolute Integrity) implanted the end of December 2014. I had none of the warning signs that my arteries were clogging. Blood pressure was normal, and my cholesterol level was within the acceptable range also. My regular Doc didn’t like my family history of heart issues, and sent me for a heart calcium test, and it went downhill from there. I am only 48 years old. I am pretty new to the clopidogrel/aspirin combo therapy, but I would rather my Cardiologist err on the side of caution, and keep me on the regiment longer if necessary, regardless of the weird bruises I wake up with each day.
Stop now!!!! Read the research!!!
been on Plavix for 20 years after the heart attack no problems at all. if you have no problems stay on them.
Roxanne, not sure if you will see this but I was just wondering what have you read or heard about stopping Plavix? I’m on both plavix and aspirin and am so scared to officially stop it but I’m about to have surgery so I have to…cardiologist told me not to start it back. Been on it for 2 years.
Received Cypher stent in 2003. Did not have heart attack. Have been taking plavix and baby aspirin for 16+ years. Have horrible bruising on arms and scalp itching. My cardiologist says stay on meds indefinitely. I’m so confused I don’t know what to do, given the conflicting reports and studies.
Joe – It *IS* confusing for patients without question. And while there are a number of studies and debates at professional meetings, one thing seems pretty much agreed upon, which is that the decision about duration of DAPT depends very much on the clinical situations of each individual patient. The large studies help give general guidance on these issues, but many factors make up the recommendation: type of stent, location, size, bleeding risk of patient, etc. Having a discussion with your cardiologist about these issues is important, although it sounds like you have already had that, and his/her recommendation was to stay on DAPT.
I am 61 years old now. In 2005 I had a coated stent put in with Plavix / aspirin therapy. I was told then that I would never be off the Plavix. This spring I went in for a routine yearly check up. The doctor said I am taking you off the Plavix. I said I thought I was told that was indefinite med. She said things change, I may end up putting you back on in 6 months. Well that makes me nervous
What is all that about ? From articles I am reading the coated stent can put out overgrowth and block the artery. Should I be worried about this?
Barbara – The recent studies looked at Plavix and aspirin for 12 months vs. 30 months. There really is no trial data measuring the effectiveness of this regimen for long periods such as yours (10 years). Just FYI, Plavix does not prevent the stent from tissue regrowth. It is meant to keep blood from clotting inside the stent. Once the endothelial lining of the artery grows over the stent struts, this risk is greatly reduced. The potential benefits from staying are Plavix are more related to the benefits of the drug itself, rather than how it interacts with the stent. The risk of staying on Plavix is mainly the possibility of bleeding. This is a complicated topic, and you can read more about it in our article on the DAPT study.“
You wrote : “Once the endothelial lining of the artery grows over the stent struts, this risk is greatly reduced.”
How long will that process take?
Hi Alex/John – depending on the stent itself, the process of coverage can take anywhere from 1 to 6 months (or more) – and if that sounds like a wide margin, it is, because stent strut coverage can be affected by a number of factors. But the newest stents are now in trials of short DAPT periods, based on findings of intravascular imaging of OCT (Optical Coherence Tomography) that visually shows stent coverage. In short, the newer stents show far faster coverage than the first generation from a decade-plus ago.
I suffered from IWMI mild heart attack. After eight months of medications on Deplatt75 mg, and Plavix40mg I developed Myositis. Then I stopped taking Plavix40mg. But continued taking Deplatt75mg. I take one pomegranate, two seacod capsule, a spoon of flax seeds, five pieces of almonds, a piece of walnut on daily basis. Sometimes I take a piece of meat. I walk 2kms five to six times a week. I drink 2 pegs of whiskey a day. So far so good with no heart problems.
In 2008 had 3 stents implanted, 2010 one went bad and had another 2 implanted, still on Plavix and a baby aspirin – glad to be typing today. Just wish we could work on lowering the production of cholesterol. I’d love to live to 65.
I had stents put in 3 months ago and I am on plavix . Now I am pretty much impotent. Can I stop the plavix and just use aspirin.
Hmmm, I would discuss this with my Cardiologist. Maybe he can reduce the dosage and help you out.
Michael – I wonder if you are also on a beta blocker? You dont say if they put in the stents due to a blockage/MI. When I had my MI with blockage and got stents I was placed on Coreg as well as Plavix. The Coreg played hell with my ability to get an erection. Once I was off it, all was well. Actually, all was “much better” because my heart was functioning a hell of a lot better after the stents. My wife was thrilled 🙂 I dont know if Plavix has a side effect of ED but that hasnt happened with me. Beta blockers definitely do (because they cause your heart to not beat as hard which can reduce blood flow to extremities).
I am a 51 YO male/2 kissing stents from Sept 2014/ 100% blockage of LAD. Still on DAPT after 18 months. Hoping to drop the Plavix after 2 years.
Michael, I spoke to my cardiologist about continuing the daily 5mg Cialis, I was warned against it by my GP, the specialist said that there is no interaction between the two, the concern is that if needed nitro and Cialis may lower your BP to a dangerous levels. I’m one month away from a heart attack and on Plavix. He agreed that a compromise to taking 2 Cialis on the day of intimacy should be OK. It works great, the thinner blood and opened vessels brig art all back to normal. BTW I’ve been doing that for 5 years and Cialis had no effect o my BP. Now we are all different so caution should be the word here.
Had 2 stents put in December 8th, 2015. On Plavix and Aspirin. Doctor said for at least 1 year or more. I still worry about restenosis? Isn’t there a way for the doctors to periodically check to make sure arteries are not restenosing that is not invasive? Seems like this would catch any problems that may happen before a heart attack, etc.
Had a no-eluting metal stent implanted during a “surprise” (no prior symptoms) heart attack 12 years ago (2003). I have been on Plavix w/aspirin for all of the 12 years and have regular stress testing very often combined with CCT. Recently repeated the stress/CCT test and am awaiting the results but feel lucky to have had an event-free 12 years and counting (I hope) while continuing on Plavix/aspirin regimen.
For 12 years taking Plavix/aspirin did you have any complications?
I guess that a heart cath would tell, but I don’t know if any doc would do that or if insurance would pay for it. I see my doc’s NP in a couple of days and I’ll ask her and re-post a reply.
I had 3 stents placed 1 year ago doc just took me
Off plavix I am nervous about it to,me only
I was 44 in October 2014 when I had 2 DES placed back to back in my LAD. 100% blocked and didn’t want to let blood flow well enough after placing the 1st stent so he put the 2nd in. After 1 year I was taken off of Plavix but I continue taking a 325mg aspirin every day. It’s been a year now off the Plavix with no negative issues. I was worried for a couple months because you know how they tell you to never miss your Plavix or aspirin. Hang in there man, you’ll be alright.
Did Dr. give you Liptor to lower cholesterol? I was wondering if I can be off Lipitor bc of side effects. My levels are down.
I think the single 325mg aspirin did more than the DAPT wc included the Plavix. The 325mg aspirin could hurt the stomach badly
Alex/John – There are some recent studies that suggest the possibility of dropping aspirin from DAPT, since it may not have a added benefit after all. But DAPT duration depends on many factors, and for those patients especially who had heart attacks or acute coronary syndromes (ACS) longer DAPT (incl aspirin) is definitely recommended.
Why would your doctor take you off Plavix ? How long did you take it?
I’m a 61 year old male and I had a Resolute Integrity stent put in my Circumflex Artery 5 days ago. My blood pressure had been getting dangerously high for no reason and my heart was racing on an intermittent basis. My heart doc asked if he could do a heart cath to determine if I had any blockage. I asked if we could do another Nuclear Stress Test, which was normal 20 months ago, and he said that he would prefer to take a look with a cath.
Since heart disease doesn’t run in my family and since I researched the heart cath process thoroughly, I figured that I’d roll the dice and find out once and for all if I had any blockage.
Well, I woke up and found out that I had a 15 mm X 3.0 mm stent in my Circumflex Artery due to 70% blockage. I’m still in shock. I had discussed with my doctor, in a prior visit, that if I had any blockage I would be willing to get on statins and modify my diet in hopes of cleaning out any plaque.
So, now I have stent and I’m worrying about all kinds of things. I’m hoping that the arterial wall will grow over my stent with no issues and that I’ll be able to come off of the thinners at some point down the road.
BTW, the thought of an embolism scares the heck out of me. I’m already being treated for anxiety and I didn’t need this.
Any words of encouragement out there?
John – A few thoughts. We at Angioplasty.Org stress the importance of having patient-physician discussions regarding any treatment for heart disease. When a diagnostic catheterization is performed, and then turns into an angioplasty/stent procedure in the same session, it’s called an ad-hoc angioplasty. I discussed this at length in my post from 2012, “Ad Hoc Angioplasty: The Patient Is On The Table.” We don’t comment on medical decisions or give medical advice, so we can’t address the urgency or safety issues with your specific case. But we can say that the Resolute Integrity is a bare-metal stent for which dual antiplatelet therapy is usually prescribed for a shorter period because the arterial wall covers the struts usually within six months or less. However, each anatomic situation is different and you should check with your cardiologist about this. Additionally the fact that a 3.0mm diameter stent was used would mean that your circumflex was not a narrow artery, and a 70% blockage may have been causing some of your issues, so hopefully opening it is giving you some relief (we’d like to hear any updates on your BP and heart racing). As for statins and life-style changes, they are certainly important tools in keeping coronary artery disease from progressing, but they can’t “clean out” existing plaque. Assuming your only issue was the single stenosis (blockage), that’s good news that you don’t have widespread, diffuse, multivessel disease. That’s also an ideal situation for angioplasty.
….I have been doing IV Chelation, which is well documented and medically researched….Chelations removes the excess Calcium that has accumulated over the years as well as other heavy metals such as lead and mercury etc….I had arteries that were 40 percent blocked as well as I have three Resolute Integrity Zorarolima-eluting stents in arteries that were 70% and 90% blocked….when rechecked the arteries that used to be 40% are completely clear….you just have to take my word for it and do the research….it works…I say stay on the Plavix for the year if you can and then get off of it, but continue with the baby aspirin for life….and once a year do five chelation treatments in a year…this will clear all the arteries and keep the stent clean…
Thank you for this explanation. I had an Ad Hoc Angioplasty during a diagnostic catheterization in 8/2018 & awoke w/ a DES in my LAD which was 85% blocked. Another vessel , untouched was 40% blocked. Been on ticagrelor & ASA for 32 months with typical side effects. I have an appt. this week for renewed discussion. My cardiologist states discontinuing ticagrelor at this point is a “grey area”.
I had exactly the same problems as you, 2 stents (2014 & 2016),. My advice to you is to start living and not worry about what may or may not happen. Takes a lot of energy to live in fear when you could use that energy to focus on the positive. My doctor is a true advocate for his patients, he had talked to me about taking EECP treatments. I took the plunge and committed myself to 35 treatments, much to my surprise was the best decision I could of made. Have 2 acres that is landscaped and manicured and at 70 I’m able to now garden, mow, trim, physical activities. Before the treatments I was limited, am now an advocate for the EECP treatments. LOL
john, it’s best u follow yr own gut. stents will not prevent heart attacks. it may not even alleviate yr chest pains. diet and. exercise and living stress free would be ideal. Leave the rest up to God
Thanks for the reply!!!
I’m obviously not a cardiologist (I’m actually an engineer, so analyzing everything is engrained in me.) Today, I had my one week follow up visit with my cardiologist’s NP. Very nice young lady with one year of experience. Aaargh!!! She didn’t say much except to take my meds as instructed and go to the ER if I have any chest pains. She explained a little bit about what they did to me and she was surprised when I told her that my cardiologist didn’t discuss the details of the cath procedure with me and what the options were if he found any blockage.
She said that she would pass on to my cardiologist that I’m not happy that he never discussed anything but taking a “look see” in my heart. We never had a discussion of what he might do if he found any blockage of significant value. If we did, I would have told him that unless it’s “life threatening,” I’d like to try diet and statins, which I’ve never been on.
As far as reversing plaque in one’s arteries, I spoke to a 90 year old man yesterday that told me that 15+ years ago, they found that he had 50% to 70% blockage in his coronary arteries and they wanted to do stents at the time. Instead, he made an appointment with Dr. Gould of the UT Houston Medical School and through diet, lifestyle changes, statins and exercise, he is plaque free today. I’m no expert on heart disease, but unless he is lying to me, he is proof that plaque is something that can be reversed in some people if they make the effort.
Unfortunately, some of us want to take a pill or have a procedure done to fix a lifetime of neglect when maybe we can mitigate our problems with good nutrition, diet and exercise.
Thanks again for the reply,
Thanks for the update, John. Your new (young female) cardiologist seems right on. This conversation should have been had before your cath (which was the point of our 2012 blog post). Of course, this doesn’t mean that your interventional cardiologist’s decision was incorrect. But it should have been discussed with you, so that you had the chance to understand your clinical situation. As for reversing plaque, Dr. Gould is a highly-regarded cardiologist and has written a book titled, “Heal Your Heart: How You Can Prevent or Reverse Heart Disease.” Whether it is possible to eliminate a 70% blockage is questionable. But certainly angioplasty does not “cure” coronary artery disease. No one claims that. What angioplasty or stenting does is reset the risk factor, giving the patient time to make the modifiable lifestyle changes necessary to prevent further progression of the disease. Again, thank you for sharing your experience.
Well, I went and saw Dr. Gould and my blockage was 30-40% according to all of the videos of my angioplasy, not the 70% that my cardiologist told me. Dr. Gould said that I CERTAINLY did not need a stent. Also, the PET scan showed that my heart is actually in extremely good shape with no significant blockage whatsoever.
So, now I have chest pains daily that I’ve never had before, and I’m dizzy a lot. I take Plavix, aspirin, statins, BP medicine and my anxiety level keeps me up at night. So much for the Hippocratic Oath.
This all dovetails nicely with the study that I read of that indicated that as many as 2/3 of interventional cardiologist overestimate blockage, probably because placing stents is big money.
Thanks again for your reply.
I’m planning on seeing Dr. Gould in a few months as I live in Texas. I want to see how I’m doing and not just assume that I’m doing OK until something goes south. I’ll post the outcome of his PET scan and his consultation with me.
I spoke with his nurse today and she said that they have many patients who already have stents that are sent to him and the results are very positive.
What I’m looking to do now is to prevent any further buildup of plaque and learn how to live with a stent and make sure that it doesn’t re-stenosis. I’m 61 and most of the men in my family line have lived into their upper 80’s and a few into their mid 90’s. I hope that this stent won’t hamper my plan of beating all of them. 🙂
…IV Chelation for heavy metals works….that I can tell you for sure….here is a website that explains it… http://www.chelationbc.com ….
Follow up: My heart rate and blood pressure were high again this morning, so the blockage that he cleared in my circumflex artery didn’t fix it.
Also, my cardiologist knows that I have a PVC and that my heart races sometimes. I’m pretty sure that he knows that our 37 year old daughter is on two medications for the same issue that developed in her as a teenager. My personal opinion is that he jumped the gun. He told my wife while I was in recovery that the policy of their practice is that 70%+ gets a stent.
I’m scheduled to have a heart catheterization Thursday, and in all probability have a stent placed in a completely blocked artery. I had a previous cath last September, and the doctor doing the procedure decided, based on the strong collaterals I had developed to try to treat with statins, exercise and diet. I haven’t had any actual heart events, just angina. However, my angina symptoms have gotten more pronounced lately — ergo, round two.
My cardiologist told me on the phone when discussing this that I would definitely have to take Plavix for a year. After reading about the recent FDA findings on the questionable benefits of extended Plavix use, I wonder why he would be so determined that I follow that course. Any ideas?
Duration of Plavix and aspirin after stenting is variable, depending on the anatomic and clinical presentation of the blockage. A chronic total occlusion (CTO) is at higher than normal risk for restenosis, so a longer duration of dual antiplatelet therapy (DAPT) is often recommended. Of course, if the patient has a risk for bleeding, this must be taken into consideration.
My cardio doc called me the other night and explained why he had to put the stent in. He said that I could have stayed at 70% to 80% blocked for 10 years or 10 days before a heart attack or stroke may have occurred.
I asked why my Nuclear Stress Tests showed “all clear” last year and he told me that a NST isn’t 100%. I already knew that. Now I wish that years ago I had a PET scan which would have at least established a baseline for my plaque and it would have allowed me to get on statins and modify my awful diet. Now I`1l never know.
The good news is that I’m two weeks post-stent and still here.
Good Luck Jim,
I know that you are probably going to be resting for a few days. When you get your strength back, please let us know how you are doing.
I forgot to add that my doctor has me on Efferin for 2 months and then it will be Plavix for a year. I’ve never been a bleeder nor have I had any trouble with coagulation. My grandson cut my ear with his sharp fingernail the other day and it did take more time than usual for the bleeding to stop.
Also, no one in my family has ever had a stroke as far as I know. I don’t know if that means anything or if it will weigh in on any Plavix decision.
I had one Resolute Integrity Zotarolimus coronary stent placed last week for ruptured plaque in rear CA at ER. At follow up next day he said DAPT is now for life. Not one year since I’m male 58 yrs old. He based this on JACC August 2015 study. I told him we’ll see after 1 year. I told him I need to weigh the risks of thrombosus MI vs. bleeding and other side effects. He said stay off Internet and listen to me
Question: Is this now the standard in US and Europe and recommended by American Heart Assoc. Manufacturer. etc??
Question: If so. Is every male patient with des over past years going back on Plavix for life?
Question: this cardiologist that treated me was on call at ER. Who says I have to see him? I can ask for a referral correct? He is pretty old school and doesn’t like me questioning him. He said its his job to keep from having any more heart procedures. Period. He said see my reg doc for concerns with the rest of my health?
Thanks for responses
Barry – For obvious reasons, we do not agree with your cardiologist to “stay off the internet” to research your heart condition. We try to bring the latest information in this field to our readers. That being said, it’s difficult to know whether the web site you’re looking at is accurate or not. We like to think that information you find on the internet should add value to your visit with the cardiologist, not the opposite.
His prescription of Plavix for life is a pretty strong recommendation. According to your post he’s basing that on a study that appeared in the August 2015 issue of JACC. Actually there are 4 issues per month and there have been many, many studies about the optimal duration of DAPT. So we’re not sure which study he’s basing his prescription on. That being said, there are definitely clinical situations where long-term Plavix is called for.
However, to answer your question: the standard FDA recommendation is for one year of DAPT after implantation of a drug-eluting stent. In Europe it’s six months. Some studies have shown no adverse outcomes when DAPT is interrupted as early as one month in the newest 2nd and 3rd generation drug-eluting stents, which the Resolute Integrity is one of. We are in no way saying that your cardiologist’s recommendation is incorrect. And many cardiologists would say that, if you are at a low risk of bleeding complications, Plavix for life may have advantages.
If you have questions or concerns, we would recommend getting a second opinion from an interventional cardiologist. Many insurance policies will pay for such a visit.
Meanwhile, we would recommend that you browse through the topics on our Patient Forum, and also post any further comments to that Forum instead of here. You’ll benefit from other patients’ experiences as well as information from our staff.
Given the choice after having a drug eluting stent would you take brilinta 90mg bid with aspirin or plavix 75mg with aspirin for one year or more. (Assuming you were not worried about the cost and assuming you had no increased risk of bleeding)
I am post 1 week after having a Boston Scientific “Synergy” everolimus eluting stent implanted in the RCA. 6 months ago I had a “GORE” AAA endoprothesis implanted as I was found to have both illiac arteries blocked and an aneurysm. I was told only 1 year on clopidegrel with aspirin then stop the clopidegrel. Does my GORE AAA implant affect my treatment?
Female age 57, STEMI LAD 13 months ago with drug-eluding stent. I have been on aspirin and Plavix since then. I want to see my plastic surgeon for cheekbone filler. My cardio said okay to stopping the Plavix a week before injections but I am not so sure. If I stay on the Plavix…the worse that can happen is bruised cheeks for a couple weeks. I’m inclined to go with the bruising!
P.S. Also diagnosed with cardiac endothelial dysfunction via acetylcholine challenge angiogram. If I have to have chest pain everyday at least I want to look good!
Would like to get feed back. I just had a 1 DES on 5 nov 2015, and i am on combo therapy Aspirin n plavix/clopidogrel after d stent. I had a recent eye bleeding on my left eye on 28 march 2016. Suspected from d combo medication for heart. They stopped d aspirin till today but recently they have advised to restart d aspirin but i am worried of d risk of bleeding.
Can i go on with only clopidogrel
Had 2 stents in 2014, following by- pass 2013. Cardiologist today told me to stop Plavix 75mg.
I do not feel safe stopping Plavix. He said risks of bleeding may occur, I am confused! Does this increase my risk of a brain bleed??? I am still taking baby Aspirin….My concerns R, Y
I am being told this 2 years later???
Audrey – the standard course of Plavix and aspirin is one year post-stent. Some patients may do better with longer duration, some with shorter. We suggest looking at our Patient Forum for responses to these questions.
My wife had a heart attack on 5/24/16. Angioplasty discovered one artery blocked 100% and 3 more arteries blocked at 80%. Balloon was inserted because, she has Moya Moya narrowing of arteries in brain. The intervent. cardiologist didn’t put the stents and left for heart surgeon for a by pass. The heart surgeon said she won’t take a risk for open heart because of her brain condition and four stents were placed. At discharge the hospital cardiologist told her not to stop Plavix & Aspirin at any cost. Yesterday her Neurologist said shouldn’t be taking Plavix for more than 6 months, she might have bleeding in her brain. She is already having black stools and feeling weak and dizzy, even worst than before the procedure. Are there any expert Cardiologistt I can have a second opinion with in Mayo Clinic or any where in the country? I live in Massachusetts.
Zia – Your situation shows the need for a “Heart Team” where doctors from several specialties discuss a case and make a joint decision about the best course of therapy. There are a number of excellent hospitals in Massachusetts, several in Boston. What is important is to get the neurologist and cardiologist together in the same room to discuss the pros and cons of continuing or stopping dual antiplatelet therapy (Plavix and aspirin).
John, Most people don’t understand how devastating it can be to have something done to YOUR body with out your knowledge or consent. long as its done by an MD everyone acts like its ok because doctors must know best right? I say wrong! He lied to you by not disclosing what he would do if he found anything . You are right that lifestyle changes are as effective as stents in preventing future coronary problems (COURAGE Trial) . File a formal complaint with the medical board in your state. Nothing will come of it but this MD will pay price in time and expense, you can teach him lesson in honesty and not to abuse the trust his patients place in him.
Thanks Cynthia and all that have responded to my posts.
It’s March 22, 2017 and I’ve made it to 13 months post-stent. My new non-interventional cardiologist just told me that I can stop taking my Plavix and to stay on a baby aspirin for life. He’s also not too happy that I had a stent placed with only 40% blockage. I asked him about a 2008 report in JAMA that I saw that said that for the fhe first 90 days after coming off of Plavix, there is a small chance of a “rebound” effect where one’s platelets become stickier than normal and the is a slight risk of MI or stroke. He said that the risk is small and that I should come off the Plavix.
I see a lipid Dr. in a few weeks to discuss alternatives to statins as Inappear to be contraindicated due to sore tingling legs when on ststins. I’ve been off of statins for months and my recent bloodwork was:
Total Cholesterol 170
My numbers appear.decent and after doing a ton of research and reading a dozen books on heart disease ( includin The Cholesterol Myth, The Truth About Statins and Good Calories Bad Calories, I’ve decided that sugar and carbs are a whole lot worse for your arteries than fat.
Exercise and a low sugar, low carb diet have helped me lose 30 pounds in the last year and to keep it off. Now, I’m looking for the right balance of diet and exercise to help me fight off any additional plaque.
Also, someone in this thread mentioned that they had grown collaterals. That was one of the questions that I asked when I received the results of my PET scan one month after my stent. I was told that I have no sign of collateral’s because I didn’t have enough blockage to where my heart would try to grow any. I hope that helps whoever was talking about collaterals.
One final question for all that may care to chip in. I am constantly worried about having a stroke or heart attack because of this stent. Does anyone else have those thoughts and fears?
I had a DES stent placed in my main artery in my heart, I was wondering if its safe to stop the plavix now, the stent was done in may of 2015.
Bruce – The decision as to when to stop Plavix is something you should discuss with your cardiologist, preferably the interventional cardiologist who placed the stent. Normally one year is the recommended time, but each patient has different clinical profiles and it’s always important to communicate with your cardiologist, the one who best knows your situation.
Hello i am a 36 year old F that had a very unexpected MI(100%) and a DES placed apx. A year and half ago. My bmi is perfect, i am health contentious and there ‘was’ no family history. I was told all my arteries are in bad shape 50% – 70% clogged. I am on dual therapy with bp meds I haven’t even considered stopping plavix and the idea scares me. Are there consequences to taking plavix for an extremely long period? Is this a sernario where long term use is beneficial?
Hi E. As with any antiplatelet/blood-thinning medication, there is a heightened risk of bleeding in certain individuals with long-term use. That may be offset by the benefits. The recent DAPT study comparing 12 vs 33 months of clopidogrel and aspirin confirmed this. The recommendation of this and many other studies is that risk/benefit of long-term use is something that needs to be considered on an individual basis and is a topic for discussion between the cardiologist and patient (Are you at low risk for bleeding? Can the benefits of DAPT have a role in reducing future events?).
Hi.I am a 58 year old male diagnosed in June 2016 with a 70 % block in a main artery. My cardiologist recommended a stent which I received August 16. Based on my own personal research prior to, I requested a bare metal stent for 2 reasons , both related to Plavix ….the potential bleed issue and the fact that I’m only on Plavix for a month. The cardiologist doing the procedure was less than thrilled with my personal choice but was willing to respect my decision. He strongly believed that a DES was the preferred way to go. Conclusion: Even If the chance of restenosis is statistically greater with a BMS stent, I’m willing to take that chance . And now, after reading all the foregoing concerns and worries that DES patients have about Plavix, I’m more convinced than ever that I personally made a wise and informed choice. Thank you for allowing me to express my view.
Had two DES put in Arpril 30 2016. I am walking now 6 k day with significant elevation with no issue. I am on Plavix and apspirn. Having nose bleeds itching and bruising. It is almost 6 months can I stop the Plavix as in Europe the only recommend 6 months. If I do stop should I ween my self ?
Gregory – Hi and thanks for writing in. Duration of dual antiplatelet therapy (DAPT) after stenting is a highly debated topic. Actually for certain patients, the current U.S. guidelines are also six months. But a variety of characteristics may put a patient into the category of longer is better: complex lesion, complex anatomy, acute coronary syndrome, length and location of stents, whether they overlap, etc. DAPT duration is not a one-size-fits-all recommendation, so the best way to go forward is to talk to your cardiologist, preferably the one who placed the stent, about your issues with bruising. He/she would have your records and together you can discuss the pros and cons of stopping Plavix. We cannot and do not give medical advice in place of a doctor’s for this very reason.
I had a mild heart attack in April 2016 (found by troponin levels). Heart cath performed and then a resolute integrity stent placed (1st left diag artery) and was told 80% block. My cholesterol levels has always been good. Prescribed the 3 drugs and I have allergic reactions to all three. On 08/31/2016, admitted to hospital again for shortness of breath and chest pain; cardiologist did another heart cath and the stent was 40% blocked; blood work done; cholesterol is 131; I have not taken any cholesterol drugs. So if cholesterol is not causing my problems: Could I be having an allergic reaction to the stent. I do have some allergy to nickel. Cardiologist and MDs still insist I take cholesterol meds, but I am still having allergic reactions to the prescribed 3 meds; back on Brilinta and baby aspirin which still causes me to have shortness of breath and chest pain. Plavix and baby aspiring I break out in hives and have to visit allergist to assist with the hives. The Effient caused throat, eyes to swell. Needless to say that I have been having problems with prescriptions meds. There are no heart/cholesterol issues in my family history. My BP is low to low normal. So why does the MDs continue to push taking the statin and metoprolol drugs. I am really at my wits end, because something has to be causing the blockage. I have no other blockages, just the blockage where the stent is at. Any suggestions, comments. Thank you.
Correction to above: I have not taken any cholesterol/statin meds.
I had 4 drug-eluting stents put in May 2016. I have 3 in the diagonal and 1 in the LAD. I am on Effient and low dose aspirin. i have developed serious gastro problems with upper GI bleeding and the gastro doc says get off the aspirin. Is this safe?
Debra – You should run this recommendation by your cardiologist before stopping aspirin. He/she may want to make a different adjustment to your antiplatelet therapy, for example, substituting clopidogrel for Effient, or possible adding a Proton Pump Inhibitor (PPI) to lessen the GI problems.
In April of 2012 at 42 I had a resolute integrity DES placed in a straight section of my LAD. Had no other blockages. Upon leaving the hospital I took on a quest for healthy living. I stopped smoking and drinking and eating crap and began eating and living clean and exercising daily. After 2 years I stopped plavix as per my dr. I recently stopped the aspirin (75mg) because my GI dr was performing a colonoscopy. It’s been a week. Should I bother resuming the 75 mg asperin routine? after almost 5 years my stent should be completely endothelialized by now right? After almost 5 years what benefits does asperin offer a endothelialized stent?
Good question. And one you should ask your cardiologist. But you’ve done absolutely the right thing: changing your modifiable risk factors to slow or stop the progression of coronary artery disease. Congratulations!
Just wanting an opinion before i make my cardiologists apt. I had a heart attack in 2008 at age 40. Stented in LAD 2IN CF AND ONE IN RCA about 7 years later. I have been on plavix and 325mg asprin every day since 2007. I do nothing but bruise with every tap and bleeding is hard to stop. My pcp says i need the 325 since i already had a heart attack. I am afraid now that i am 51 and falling alot that when alone nobody is around. Also on 80 mil lipitor matopil and lisinapril. My cholesterol is like 85. I have 2 drinks of alcohol and i get short of breath..anyones opinion!!!
Cynthia – I suggest you post this to our Patient Forum to get other patients’ opinions. However, you should discuss your drug regimen with your cardiologist, preferably an interventional cardiologist. Not that your PCP isn’t informed, but recommendations are constantly changing. Possibly some adjustments are in order, but without seeing ALL your records, etc. it’s impossible to give opinions.
Hi, Is it possible to just take plavax 4 years after DES x3 in the LAD 99% blocked. I beleive I am allergic to asprin. So would plavax do a similar function to asprin?
James – Both Plavix and aspirin are antiplatelet drugs, although they act differently. Usually, after one year, the patient is put on aspirin only, since there is a lower bleeding risk than with Plavix (clopidogrel). After four years, patients normally do not need to be on antiplatelet drugs. But this varies from patient to patient, depends on your clinical picture, numbers, location, and size of stents, etc. You should ask this question of your cardiologist and make sure you understand the why of it.
46 and had my m.i. back in 2015.
I’m on 75mg asprin and 90mg ticagrelor. Docs’ wanted to stop it after a year but I argued that new research had proven that remaining on the DEPT decreased mortality in a number of cases. Doc not happy but cardiologist backed me up. Asprin is causing me all sorts of GI issues. I really want to come off of it? I don’t understand why I need to take both, I would prefer just to take the ticagrelor. What is in asprin that isn’t covered by the tic?
Jon. don’t take anything that makes you uncomfortable. it’s that simple. Not sure why some Drs. insist on people taking something that their body rejects. Common sense should dictate. it’s stupid to take any two drugs that would do same job. How stupid are some drs.
I’m a 70 year old male. Had a 4xCABG in 1999. I’m a serious recreational cyclist that has both my bicycle and I electronically wired to measure all levels of physiological performance while riding. About one year ago I noticed a rapid decline in power output but no changes in heart performance. Than about eight months ago my heart began to show definitive signs of reduced performance. CT angiogram showed all good except 70 percent stenosis in LMCA saphenous graft before the bifurcation of the LMCA/LDA/LC. Had an unexpanded 3mm stent implanted and expanded after the angioplasty. Instant return to normal for heart function under intense exercise. Now I have to decide on how long to continue DAPT.
Most of these posts talk about taking Plavix/Aspirin if there is no risk of bleeding. In my case there is significant risk of bleeding. Prior to my angiogram I was placed on coated Aspirin 81 mg. daily and 11 days later my hemoglobin had fallen 30 points. I was treated for the low hemoglobin and had an angioplasty and 2 bare metal stents were installed. I was prescribed Aspirin/Plavix after wards and after 4 weeks my hemoglobin had fallen to 65 and I had extensive stomach bleeding. The gastroenterologist stopped the Plavix and the cardiologist agreed but wants me to stay on aspirin for as long as possible. Are there no alternatives for me?
I had 2 drug eluding stents done, lad and circumflex in 2010 while on vacation. Dr who did them said I would be on Plavix for life. After returning home my Cardiologist said I would be on Plavix for life. Just moved to Fla in 2017 and new Cardiologist says I can come off Plavix now as I Do not need it. I am confused.
Charles – It is definitely a confusing topic. The optimal duration of DAPT (Dual AntiPlatelet Therapy: aspirin plus Plavix) has been a matter of much discussion over the years, as evidenced in our blog post. Our best advice is to discuss with your cardiologist why s(he) feels it’s safe to stop Plavix, when others have recommended it for life. There is a risk of bleeding when a patient is on long-term DAPT, but there are many variables, and long-term DAPT may have benefits as well. There is a DAPT scoring method that can be used to predict the risk/benefit detailed here > http://www.acc.org/latest-in-cardiology/features/dual-antiplatelet-therapy-dapt-focused-update-hub/resources/using-the-dapt-score-to-predict-stent-thrombosis-vs-bleeding
I had a similar experience, at first my cardiologist said take for life the. A couple of years later he asked why I was taking it??? I just want the right answer I have been taking DAPT for 5 years now.
I was first diagnosed with heart disease in 2001 at age 54. I am now 70.
I am left hearted which means that my heart’s natural source of oxenageted blood is 5% right main artery and 95% left main artery – rather than the typical 60/40 split between right and left.
So, for left hearted persons, a significant block of the left main artery is quite serious.
My left main was stented in 2001 and held up for about 10 years and then restented. About a year later, a second restenosis occurred and a robotic double bypass using both of my mammary arteries was performed by Dr. Joseph Benati at the University of Maryland.
Unfortunately, my left main was not my only problem. Along the way, I had numerous other blockages, which caused serious angina. All the blockages were all stented and restented.
Apparently, heavy arterial calcification is the culprit in my case. I have not suffered a heart attack.
The latest serious angina was last fall. During the subsequent cath, it was determined that my bypass arteries were both clear, so, the doctor decided to reopen the left main, which had been closed since the time of my robotic double bypass 6 years prior.
My heart stopped during the procedure and I had to be “revived” on the operating table.
Shortly after the last procedure, I learned about an electronic device called a Bemer, which is approved in the U. S. For circulation issues, (but not specifically for heart issues). Cost: approximately $7,000 and not covered by insurance.
After significant research, which included talking to cardiologists and patients who recommend the device, I have been using it for one year without angina. Either the science works (stimulates the creation of capillaries all over the body, including the heart) or the placebo affect is powerful in this case or both – as I have been angina free and playing tennis 8-10 hours per week since acquiring the machine.
It’s great to be alive and feeling good again!
Interesting story. Also, looking at this patient posting in light of the ORBITA trial, one might ask if in fact the placebo effect was at work. We would like to emphasize that, as the patient notes, the Bemer device is not approved for use in heart disease, but for peripheral cases. That being said, angioplasty was first utilized in the leg (peripheral) and its inventor, Dr. Charles Dotter, thought that “perhaps it might have a future application in heart disease.”
May I ask what is the “Bemer” for? And, what does it do?
I had three stents put in 11/22/17 day before thanksgiving. I was nervous but felt no ain,just trouble breathing maybe anxiety. This month 1/24/18 l had two more stents put in only this time the procedure seemed to be different. The pressure they applied hurt me, and l felt extremely exposed compared to the last time. I’m 68 and have many ailments and I’m taking lottts of meds.m! I don’t exercise yet, have bad left leg. Just scared about what to eat ,etc. Also need to lose about 100 lbs. Heard cardio rehab might be worth looking into .? Any advice would be so appreciative. Thanks, elissap
Elissa – diet and exercise (and stopping smoking, if one does) are the most important things a patient can do to help slow the progression of coronary artery disease. If you can get into a cardio rehab program, you will find help with these issues. So yes. As for the “pressure” you mention, not sure what you mean, but am assuming you’re talking about the pressure at the femoral (groin) puncture site at the end of the angioplasty. More and more, cardiologists in the U.S. are adopting the radial (wrist) site, which is used around the world. It has several advantages, one of which is the elimination of the long pressure on the femoral site.
I had a metal stent in my coronary artery in 2008, I was on Plavix and aspirin but same artery blocked same place within six months. Then they put medicated stent and I was on aspirin and Plavix five years, then my cardiologist stooped Plavix. After I stopped taking Plavix I got minor heart attack with in six months and same coronary artery was blocked. Got another stent sept 2015, since then I been on aspirin and Brilinta. My cardiologist wants to stop Brilinta now. What could happen if I stop? Artery could get blocked again?
Baldev – Thanks for sharing. What you’ve experienced is called “in-stent restenosis” or ISR. It’s a problem in a small percentage of patients where the blockage keeps coming back. The purpose of antiplatelet drugs, such as Plavix or Brilinta, is to keep the blood from forming a clot, specifically at the site of the previous blockage. In our Patients Forum we have had a number of patients write that within a few months after stopping Plavix, they had a heart attack, just as in your case. It’s been thought that there might be some sort of rebound effect, but that has not been verified through any studies. But there are several reasons why the original stented area may have become blocked again. Did the cardiologist who placed the second stent have any comment on this?
I had a heart attack in Dec 2015 (age 50), but didn’t realize I had one for three days (just had back pain, thought I had injured my back working on my roof) – when I finally went to hospital, my troponin level was still at 9 on the fourth day, but angiogram did not find any significant blockage (50% in one artery, but flow not restricted). Heart damage at bottom of heart, but nothing needed to be done – placed on aspirin, clopidogrel, and Metropolol. Left ejection fraction was at 50%, now 54%…my cardiologist says it is time to stop clopidogrel, but I’m afraid to! Bruise VERY easily, but no other serious bleeding. My cardiologist said he was 90% sure my heart attack was caused by a blood clot, and with a strong family history of heart problems, I’m curious if I fall into a long-term group where plavix should be continued (and since I’ve never had any bleeding issues). I have no stents, but probably will one day need them, based on family history of older brothers who have them. My 6th month appt was today, and my cardiologist said to either stop aspirin or plavix – I don’t need both – and basically gave me the choice. From what I’ve read here, maybe I should stop plavix and stay on the aspirin? This is a decision I’m having a hard time making for myself, and I’m fearful of stopping either one.
David – This is a complicated question, and one which is still being debated, for example, this very weekend at the annual American College of Cardiology meeting in Florida. We cannot and do not give medical advice. That being said, it is interesting that you had a heart attack, but have no significant blockages. It’s known that unstable lipid-rich plaques can erupt, causing blood clots (thrombi) in the artery. The clots restrict blood flow which causes damage to the heart muscle, if not treated quickly (recommendation is 90 minutes). After four days, it’s likely that the clot resolved, which is why the angiogram didn’t show a big blockage. These unstable plaques can be 50% or less. This is pretty much what your cardiologist told you. We’re putting your question via Twitter to a number of cardiologists, so check back in a couple days.
Thanks! Always appreciate any information on this topic. The 50% blockage is definitely “soft plaque”, as two years prior I had the scan where they look for the hard plaque and give a percentage – and it showed 0%! They said then the test doesn’t pick up soft plaque. The cardiologist was stunned when he reviewed this after my heart attack. Looks like I’m in the rare 1 or 2% who have a heart attack within a few years of the scan, even after showing no hard plaque.
David – I decided to put your question to our Twitter followers (mostly cardiologists and healthcare professionals in this field) and 100 responded to our Twitter Poll on DAPT. Again, this is not medical advice, but it is interesting as to their opinions (and these are opinions without having the benefit of having your medical records available, other than the quick description in the poll). The results are as follows: 71% voted that you should continue on aspirin only; 21% would recommend staying on DAPT (aspirin and clopidogrel); only 8% went with clopidogrel only.
Thank You! That is a big help! Really appreciate it! It is interesting the divergence regarding DAPT or Aspirin.
Hi female 72 years old. Family history heart disease three children out of four open heart surgery. I had open heart surgery 1998 90% main coronary artery, 50% aorta. In 2008 three cypher diluting stents was on aspirin 80 mg, Plavix 75 mg daily
For 17 years. Due to huge bruises and Heart doctor said keep taking it plus joints were very painful. I changed heart Doctor and my new doctor took me off Plavix. I had a test showed light heart attack while back. Will be having a heart catch this week. I have pains in my chest and very fatigue. Thank you very much
I find this site to be most useful. I am a 60 yr old male who has had four stents inserted since 2014, with the most recent being January of this year. I have a family history of cardio issues on both sides. I am very active including running, cycling, hiking, golfing without a cart and at least three gym workouts a week. My weight is in line with my height at 5’9″ 155. I am on a regimen of 40 mg of Crestor, baby aspirin, plavix, beta blocker, vitamins. I have never smoked. Despite all of this the blockages seem to continue. I recently researched oils and have found mixed reviews on the Omega 6s such as olive oil, particularly cooked. I was sauteeing salmon and skinless chicken in olive oil and have since switched to Omega 3 based oils such as walnut or flax. In addition, I have greatly increased my intake of cooked greens such as kale and spinach with all meals and have added lots of fresh fruits and veggies while eliminating added sugars.
My current questions are around the use of oils. Has anyone else switched out of Omega 6 oils to Omega 3s? If so, have they seen improved cholesterol test results, particularly reduced LDL? My recent LDL level was 70 and the cardiologist would like to see it at 50 or below. Also, I treat myself to fresh ground almond butter on whole wheat toast each morning after my oatmeal. Does anyone know of any downside with LDL tied to almond butter consumption?
I’m in a similar situation: DES stent placed Nov 2017 in RCX; no stent in 70% blocked LAD. I took on a vegan diet, no oil at all based on Dr. Caldwell Esselstyn and Dr. Colin Campbell’s recommendations and diets. Have reduced all blood markers dramatically. LDL 40; total cholesterol 98; glucose dropped to 90 from 130, etc. I eat veggies, whole grains, and fruit. Very very little nut butter (only almond butter); no olive oil, etc. I sautée with vinegar, water, soy, etc. Check out Dr. Campbell’s web site: http://www.nutritionstudies.org! Good luck!
Thomas, Thanks very much for forwarding the link. I have read Esselstyn’s how to prevent and reverse heart disease and will also check out the Campbell information.
Dont forget the documentary “Fork and Knives” with Campbell (NetFlix)
I’m 82 and very active. But I have my mother’s problem which is high cholesterol. In 2007 I had two bare metal stents put in and my cardiologist put me on one 325mg of aspirin. No blood thinners. This year in April I had the three medicated stents put in and they put me on Plavix and one 81 mg of aspirin. On stent was to replace the old stent that had scar tissue. I hate Plavix, I had two vessels break in my right eye and sharp pains in the other. A burning feeling in my head and burning at my left side at my waste line. Also I am very tired and some days I almost sleep around the clock. I had to insist they order complete blood work. It took three calls. They said your MD should order that and I said your the ones giving me the meds., you do it. Which they did, so at the end of the week I’ll get it done. I see the doctor in August. I don’t like talking to NP or the nurse.
My point is this. I had the bare metal put in and it lasted 10.5 years. I wasn’t asked if I wanted the bare or the medicated. He just did what HE wanted. Now I’m suffering from medication that is cauings other problems like I said above. I am very upset that they didn’t give me a choice. Now they just told me if I go off of Plavix I would die.
Reba – Very sorry that you are having these reactions to Plavix. You definitely should alert your cardiologist to these issues. Most studies done to date have shown that the newer drug-eluting stents (DES) are as safe or safer than the bare-metal stents you originally had. And that the duration of DAPT (aspirin plus Plavix or equivalent) is determined more by the location and length of the stent. We’re actually surprised that you weren’t prescribed Plavix with your original bare metal stents because the standard protocol for that was 4-6 weeks of DAPT. Since one of your DES was placed inside of the old bare metal stent, the recommendation for longer use of Plavix in such cases is pretty standard. But several studies have also shown that in some situations, early cessation of DAPT with the newer generation of DES poses no increased risk. But this is not medical advice. You should discuss these issues with your cardiologist. And let us know how you fare.
8years ago i had 2 bare metal stent not the drug-eluting stent and i have aspirin as maintenance plus concor does it safe to have a tooth extraction now, I stop taken aspirin for 5days for my pre-tooth extraction
Vence – Check out our Forum Topic on the subject of dental issues and extractions (http://www.ptca.org/forumtopics/topic20050227.html). FYI, the American Dental Association does NOT recommend stopping antiplatelet therapy for a tooth extraction.
I am a 75 year old male. In 2003, I had 2 stents placed in my rear CA. In 2004, I had 1 stent placed between the first 2 stents after a heart attack. After exactly 14 years with no problems or events, I had another heart attack with blockage in the middle stent. They re-stented by placing another stent within the original stent. They told me the original stent had not been fully expanded and locked 14 years before (by a different cardiologist) and had a slight hourglass shape. I was told that they don’t like to put a stent within a stent but had no alternative other than open heart surgery. The cardiologist told me that I would take Plavix and baby aspirin for life. I had not been warned of this in 2004 and had been taken off Plavix by the attending cardiologist after 6 or 8 months. Question 1, can there be a reason why the 2004 cardiologist could not (or did not want to) fully expand the stent? Question 2, should I have been warned about the stent at the time and left on Plavix if he knew the stent was not locked in place? Or could he have not realized it was not locked? Question 3, how common is double stenting? I am 4 months post stent and doing fine but of course know that there can be no more blockage in that double stent. Thank you.
Dale – Thanks for your comments. The technical term for what occurred is In-Stent Restenosis (ISR), where tissue grows inside the stent. There are a number of reasons why this happens, an under-expanded stent being one of them. I’m guessing that your original stents were of the bare metal variety, since the first DES were approved in 2003/2004 and at that point were not routinely used in heart attack situations. Keeping ISR from occurring is one of the major reasons drug-eluting stents (DES) were developed, and they have reduced the incidence of reblocking significantly. The occurrence of ISR is small in numerical percentage but obviously important to address when it happens.
There have been a number of procedures developed that have tried to address the issue: (1) placing a new DES inside the original stent, usually a DES with a different drug than the original, if the original was a DES – this is the most common treatment for ISR; (2) simple balloon expansion to re-open the new blockage and re-expand the stent – in the future (when they are approved for such use), using drug-coated balloons, which have shown excellent results in leg arteries; (3) an older procedure, called brachytherapy, which uses radiation to prevent tissue growth.
Regarding an under-expanded stent, we have advocated for the increased use of intravascular imaging since we began our site. Two imaging methods, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are available to look at the stent placement from inside the artery itself. They involve putting a new catheter inside and additional expense, and in 2003 were seldom used in a heart attack situation. Currently they are used in less than 15-20% of cases, but they can be extremely useful in measuring exactly whether or not the stent has been fully expanded. In fact when the first bare metal stents were introduced back in the 80’s, the percentage of restenosis was quite high, until Dr. Antonio Colombo in Milan started using IVUS and saw that the vast majority of stents placed were significantly under-expanded. His studies greatly impacted the technique of stent placement and outcomes improved.
Addressing your questions: (1) I assume the original cardiologist would have fully expanded the stent, if he/she could have. Sometimes there are calcium deposits in the artery which prevent full expansion. There are several devices which can remove or “sand down” these deposits but, again, probably would not be used during a heart attack, where the goal is to re-open the artery as quickly as possible. It’s also possible that over the 14 years, there was “vessel remodeling” where the arterial wall literally changes its shape and pulls away from the implanted stent. (2) Plavix is an antiplatelet drug that keeps the blood flowing while a thin tissue layer grows over the stent struts, usually in 6 months. If the blood clots inside the stent, called thrombosis, a heart attack can occur. But you had no issues for 14 years, so the re-blockage was probably not due to thrombosis and long-term Plavix was probably not necessary during that time (there are side-effects of bleeding with Plavix). Again, it’s not an issue of the stent being “locked” in place, but an issue of excess tissue growth inside the stent causing a blockage. (3) Double-stenting, as noted, is the most common treatment for ISR. Because you now have a double layer of metal, long-term Plavix is indicated to prevent any blood clotting. Hope this helps explain some things.
I am nearly 87 and was fitted with a stent after a angina attack, whilst walking up a hill.
This was 11 years ago and the surgeon suggested I stay on Coplavix for 12 months.
The diagnostician doctor, after going for a stress test yearly, told me that I did not need to have the yearly test. However, because I mentioned the easy bruising and bleeding, he said that going off the medication would increase the chances of a fatal heart attack by about 1%.
Recently I met a chap fitted with a pacemaker who uses Eliquis and does not suffer from either bleeding or bruising. So I am about to visit my local GP to ask about Eliquis.
I had a stent in 2005. I have been on plavix and aspirin since. My current cardiologist says to stop the plavix and go to 2 baby aspirin. I bruise easy and bleed a little more than normal. I would like to stop as I take multiple drugs. I’m not sure if it is just a security blanket or if I need. Back when I started I was told it would be fore life. I am 78 and am in reasonably good health.
Looking for some guidance- my husband had a heart attack about one month ago. Had 99% occlusion of right coronary artery. Had a stent put in. Was on Brilinta 90 mg twice a day for one month, along with aspirin 81 mg daily. Due to cost, he is now switchimg to Plavix 75 mg daily and continuing on the aspirin. My questions are: should he take Plavix at bedtime or in morning AND should he take the Plavix and aspirin together? Would he have better coverage if he took aspirin in morning and Plavix at bedtime or am I overthinking this?
Pat – These are questions that really should be directed to his cardiologist, one who has his medical history and who “knows” your husband. But, when it comes to health and patients’ involvement in their own healthcare, “overthinking” is nothing to apologize for!
I’m not replying I’m telling you that I’ve been on Plavix since August,2002 after a carotid artery surgery to remove a 99% blockage with a graft from my inner thigh in August 2002.
I’m now 71 and have a duplex scan every year since 2002, I’m guessing I’ll spend the next 30 years still on Plavix because I expect to live that long.
I’ve never had another TIA after the original 3 that sent me ino surgery in 2002. I have no stent..I have a graft.
I had 4 MI’s in 2/2003. 2 on one day and 2, 4 days later. Some have called it a stuttering heart attack. In any case, it was 4 separate occasions. I remember them as if they were yesterday. I had 2 large non drug stents placed in 2 arteries that were 100% blocked. I was told I still had a 90% blocked artery. I took cardiac rehab for 6 months. After 3 months had nuclear stress test. Doc was very pleased with results so I stayed in rehab for 3 more months. I have been on 325 MG Aspirin and 75 MG Plavix for 16 years. I also changed my diet and I exercise. 2 years ago I was Dx with prostate cancer. Had HDR, High Dose Radiation treatments. Recently I started bleeding from the prostate. The urologist was reminded I was taking the Aspirin and Plavix and he said I had to stop one of them. I stopped the Aspirin. Bleeding continued. I stopped the Plavix. I have not seen a cardiologist for 10 years. I heard of too many people having MI’s after stopping Plavix so I continued for 16 years. I just started taking 81MG aspirin and NO Plavix for the last 2 weeks. I still exercise for 1.5 hours at gym 3 times a week. 1 hour on treadmill. I’m concerned that since I had success for 16 years that my luck will soon run out. If anyone has suggestions, I would welcome them. The bleeding seems to have stopped but I am thinking I should now see a cardiologist.
I am white male, 65 years old. My 4 MI’s I was 49 and otherwise in good shape. John
This is a very very hard decision to go off plavix and aspirin/ My heart doctor just talked to me about it and I am very scared/ I have been on both for 8 years. I don;t plan on going anywhere as I have 12 grandkids and and 58 which I had my heart attack when I was about 49. She said I should be fine and she has no worries. i just don;t know what to do???
Thanks guys and dr cardios for the fantastic response and feed back i had 3 des done with all having 90 blockages in march 2019 i was given tricalgelor 90 twice and one aspririn 75 with ruvastatin 20 now arounnd 14 months over i went done heart echo and the dr advised me to take asprin 75 twice with one of clopidefgrol 75 with ruvstatin 20 for life long i am 65 healthy male doing walking indoor cycling and take a good gluthaione anti oxidant green smoothies i dont have any pain my advice is to to carry on the dapt as long as you can forget the bleeding thing always have these med with good diet food to kill the acidity and not on empty stomach thanks and can also feel to write to me be chirpy live life full god gave you 2 nd life so thank him GOOD BLESS ALL
Sir my simple querry is that will iget internalbleeding now i had been stented 90 % blockage with 3 DES in march 2019 with dosage of 180 tricagelor and 75 aspirin and Ruva stat 20 after having a routine check NOW with DR I was told to go for cbc echo cardio showing 65 EF with lipids and sugar and bp levels in control i have been given dosage 75 twice aspirin and 75 clopidegrol once with Ruvastatin 20 B….i dont have any pain but want to ask if after 18monhs of dapt went well wihout pain or restonsis or blockage IS THERR ANY CHANCE OF INTERRNAL BLEEDNING NOW or when THATS MY WORRY dr SAID THE CHANCES ARE 10% of bleeding BUT 90 IF YOU STOP OR REDUCE THE DOSAGE of attack…..kiNDLY MR BURR ADVISE ME THANKS pl do reply
I would like to know if I’m a good candidate for getting off generic form of plavix and aspirin. I had Angina, chest pain with exertion and extreme sudden cold. I ended up with the smallest stent. Almost three months ago now. Am I a good candidate for discontinuing in the 3 to 6 month range? I have a plan to use alternative supplements to help keep the blood thinner and less sticky without the risk of bleeding.
As we’ve reported, discontinuation of antiplatelet therapy after stenting is a complex issue. You should ask your cardiologist, preferably the interventional cardiologist who placed the stent, these questions because he/she would have more data regarding the location of your stent, the size, the type of stent, etc.