Antiplatelet Therapy
Nine cases on antiplatelet drug selection and duration — choose a case below to open its full multi-voice debate.
A single patient, thirty days from a two-stent bifurcation PCI. The disagreement isn't about whether she still needs dual antiplatelet therapy — it's about which half of the regimen she can no longer safely continue, and for how much longer.
A single patient, less than an hour past a stented NSTEMI, whose chart already carries one closed chapter of GI bleeding. The disagreement isn't about whether he needs a second antiplatelet on top of aspirin — it's about which one is safe to add given his bleeding history.
A single patient, his calculated ten-year cardiovascular risk sitting just under the threshold most guidelines use before they'll even discuss aspirin. The disagreement isn't about his risk calculation — it's about how much weight a family history the calculator doesn't ask about should carry.
A single patient, thirty-six hours into a mild cryptogenic stroke with an incidental PFO already judged more likely bystander than cause. The disagreement isn't about whether to close anything — it's about which antiplatelet regimen, and for how long, to build his secondary prevention around now that he's arrived just past the window the trials were actually built on.
His clopidogrel failed clinically before anyone tested why. The genotype explained it after the fact; the real decision is which drug replaces it in a man whose job puts him behind the wheel eleven hours at a stretch.
Two major trials tell two different true stories about P2Y12 inhibition in diabetics — one about a subgroup that benefited more, one about a drug that didn't care whether you had diabetes at all. No trial has ever compared the two agents directly in this population.
One large trial found that adding ticagrelor to aspirin protects his vein grafts. Another, just as large, found it doesn't. A third, newer trial suggests the real answer may be a matter of how long, not whether.
AHA and SVS say thirty days is enough. The European vascular society says three months. Neither is wrong, and the gap between them is where his actual prescription has to land.
A single patient carrying a coronary device few cardiologists still implant, whose antiplatelet duration question has no dedicated guideline written for exactly her situation.