Medications After Balloon Angioplasty

1. Antiplatelet Therapy (most important class)

• Aspirin 75-81 mg/day - indefinitely (lifelong secondary prevention)
• Clopidogrel 75 mg/day - for 3-4 weeks after plain balloon angioplasty alone (without stenting), then may be discontinued

For patients receiving a bare-metal stent or balloon angioplasty alone without stenting, clopidogrel may be administered for 3 to 4 weeks. For drug-eluting stents, DAPT is continued for a minimum of 1 year.

• Textbook of Family Medicine 9e

2. Statin Therapy

• High-intensity statin: Atorvastatin 40-80 mg/day OR Rosuvastatin 20-40 mg/day
• Target: LDL-C reduction of ≥50% from baseline, with a goal LDL-C <55 mg/dL (ESC 2024 / very high risk) or <70 mg/dL (minimum)
• If LDL-C target not reached with statin alone, add ezetimibe 10 mg/day
• If still not at target, consider PCSK9 inhibitor (evolocumab or alirocumab)
• Statins are continued indefinitely - they must not be stopped

3. Beta-Blockers

• Indicated if the patient has: reduced LV function (EF <40%), prior MI, angina, or heart failure
• Commonly used: Metoprolol succinate (extended release), Bisoprolol, or Carvedilol
• Target resting heart rate: 55-60 bpm
• In elderly patients, start low and titrate slowly; watch for bradycardia and hypotension

4. ACE Inhibitor / ARB

• Indicated if: LV dysfunction (EF <40%), heart failure, hypertension, diabetes, or CKD
• Examples: Ramipril 2.5-10 mg/day, Enalapril, Perindopril
• ARB (e.g., Valsartan, Candesartan) if ACE inhibitor is not tolerated (dry cough)
• In elderly patients, monitor renal function and potassium after initiation

5. Nitrates (if symptomatic angina persists)

• Sublingual nitroglycerin - for breakthrough angina episodes (on-demand)
• Long-acting nitrates (e.g., Isosorbide mononitrate) if chronic angina symptoms persist post-procedure
• Note: A nitrate-free interval of 8-12 hours/day is required to prevent tolerance

6. Additional Medications Based on Comorbidities

Special Considerations in a 70-Year-Old

• Polypharmacy risk: Elderly patients are prone to drug interactions and adverse effects. Review the full medication list.
• Renal function: eGFR should guide dosing of renally-cleared drugs (direct thienopyridines, DOACs, metformin)
• Bleeding risk: Higher in elderly - use the lowest effective aspirin dose (75-81 mg), consider PPI (omeprazole or pantoprazole) to protect the stomach while on DAPT
• Falls risk: Antihypertensives in the elderly can cause orthostatic hypotension - monitor BP, especially when starting or titrating
• Ranolazine (500-1000 mg BID): A useful add-on for refractory angina in elderly patients who cannot tolerate heart rate-lowering drugs, as it does not affect BP or heart rate

Medication Summary Table

Clinical reminder: Always individualize therapy based on the patient's full clinical profile, comorbidities, renal/hepatic function, and bleeding risk. The above is a framework, not a substitute for clinical judgment.