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Overview
A new advisory  1 from the American Heart Association, the American Dental Association and three other agencies recommends that patients with drug-eluting stents (DES) continue dual antiplatelet therapy for at least one year after implantation. The joint advisory, published in the journal Circulation , received online news coverage from the Associated Press ,2 the American Heart Association 3,4 and Medical News Today .5
The advisory statement strongly recommends against premature discontinuation of antiplatelet (anti-clotting) therapy for patients who have implanted drug-eluting stents, particularly within the first 12 months after placement. This recommendation is intended to educate health care providers and patients about the “potentially catastrophic risks” faced by DES recipients who are taken off antiplatelet medications.1 The recommendation is also supported by recently published studies, which suggested that DES-treated patients who stopped antiplatelet therapy were at increased risk of acute myocardial infarction and/or death.
Patients with drug-eluting stents receive slow-release medication directly into an arterial wall to inhibit the formation of scar tissue, a condition known as in-stent restenosis (reblockage). To minimize the risk of reblockage after DES implantation, patients are typically maintained on a dual antiplatelet regimen: aspirin with either clopidogrel (Plavix) or ticlopidine (Ticlid). Today, more patients have drug-eluting stents than ever before, and dual antiplatelet therapy is commonly prescribed for DES recipients. Yet when those patients require simple oral surgery, they are sometimes advised by physicians or dentists to discontinue their anticoagulation therapy.
As noted in the new advisory and a November 2003 JADA article ,6 the literature does not support early cessation of anticlotting medications before receiving dental treatment, and there are no well-documented cases of clinically significant bleeding following dental procedures, including multiple extractions. The multi-agency writing group, which developed the new advisory, agreed with a joint clinical practice recommendation for 12 months of dual antiplatelet agents after DES implantation. The advisory urges health care providers to work in full collaboration to ensure optimal patient care and to thoroughly educate DES recipients about the significant risks associated with early cessation of antiplatelet therapy.
Dentists should be fully aware of the potential risks of premature discontinuation of antiplatelet therapy for patients with drug-eluting stents. The advisory recommends that elective procedures with significant risks of bleeding be deferred until completion of the course of antiplatelet therapy, which is at least 12 months after DES placement, or at least one month after non-drug-coated stent placement. Dentists who perform invasive or surgical procedures on stent patients should take a comprehensive medical history and contact the treating cardiologist if questions arise regarding the patient’s antiplatelet therapy. Additional information is available in the full report from the advisory panel .
Footnotes
1Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, O'gara P, Whitlow P. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. A Science Advisory From the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, With Representation From the American College of Physicians. Circulation. 2007 Jan 15; [Epub ahead of print]. Available at: http://circ.ahajournals.org/cgi/reprint/ CIRCULATIONAHA.106.180944v1 . Accessed January 17, 2007.
2 Stengle J. Anti-clot drugs urged for stent patients. Associated Press, Available at: http://news.yahoo.com/s/ap/20070116/ap_on_he_me/heart_stents . Accessed January 17, 2007.
3 American Heart Association. Patients who receive drug-eluting stents should continue antiplatelet medications for at least one year (press release). January 16, 2007. Available at:
http://www.americanheart.org/presenter.jhtml?identifier=3044640 . Accessed January 25, 2007.
4 American Heart Association. Joint statement on extending dual antiplatelet therapy to one year post-DES includes surgeons, dentists (press release). Available at: http://www.theheart.org/article/765185.do . Accessed January 17, 2007.
5Paddock C. Patients with drug-eluting stents should take anti-platelet medication for 12 months to avoid fatal heart attacks. Medical News Today, January 17, 2007.
6Jeske AH, Suchko GD. Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. J Am Dent Assoc 2003 Nov;134(11):1492-7. Available at: http://jada.ada.org/cgi/content/abstract/134/11/1492 .
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Science in the News is a service by the American Dental Association (ADA) to present current information about science topics in the news. The ADA is a professional association of dentists committed to the public's oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards. As a science-based organization, the ADA's evaluation of the scientific evidence may change as more information becomes available. Your thoughts would be greatly appreciated.
Page Posted January 2007
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