What is the most appropriate initial dual antiplatelet therapy for a 63-year-old male with non-ST-segment elevation myocardial infarction (NSTEMI) and coronary artery stenosis, post-percutaneous coronary intervention (PCI) with drug-eluting stents (DES)?

From the Guidelines

The most appropriate initial dual antiplatelet therapy recommendation for MZ at this time is aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 12 months. This regimen is recommended for patients who have undergone percutaneous coronary intervention (PCI) with drug-eluting stent placement following a non-ST-segment elevation myocardial infarction (NSTEMI) 1. The combination of low-dose aspirin with a potent P2Y12 inhibitor like ticagrelor provides superior protection against stent thrombosis and recurrent cardiovascular events compared to aspirin plus clopidogrel. Some key points to consider in this decision include:

• The patient's weight is 94 kg, which is above the threshold where dose adjustment of prasugrel is recommended, making ticagrelor a more suitable option 1.
• The patient has multiple comorbidities, including hypertension, type 2 diabetes, and dyslipidemia, which increase the risk of recurrent cardiovascular events and support the use of a potent P2Y12 inhibitor like ticagrelor 1.
• The 12-month duration is standard for patients with acute coronary syndrome who receive drug-eluting stents to allow for complete endothelialization of the stent and to reduce the risk of late stent thrombosis 1. Some important considerations for the use of ticagrelor include:
• The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily 1.
• Ticagrelor should be discontinued at least 5 days before any surgery 1.
• Issues of patient compliance may be especially important with ticagrelor, given its twice-daily dosing regimen 1.

From the FDA Drug Label

In patients ≥75 years of age, prasugrel is generally not recommended, because of the increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior myocardial infarction [MI]) where its effect appears to be greater and its use may be considered Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) Initiate prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily. Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The most appropriate initial dual antiplatelet therapy recommendation for MZ at this time is Aspirin 81 mg daily plus prasugrel 10 mg daily for 12 months is not listed, but Aspirin 325 mg daily plus prasugrel 5 mg daily for 12 months could be considered given the patient's weight is 94 kg, which is above the 60 kg threshold where a 10 mg dose is recommended, and a 5 mg dose is considered for patients <60 kg. However, the patient's age is 63, which is below the 75 years of age threshold where prasugrel is generally not recommended. Given the options, Aspirin 325 mg daily plus prasugrel 5 mg daily for 12 months is not listed, but Aspirin 325 mg daily plus prasugrel 5 mg daily could be considered if the dose was 10 mg, but since that option is not available, the next best option is Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 12 months or Aspirin 325 mg daily plus prasugrel 5 mg daily for 12 months if it were an option, but since it is not, then Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 12 months is the best choice given the patient's profile. However, the best choice given the options is Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 12 months. 2

From the Research

Dual Antiplatelet Therapy Recommendation

The most appropriate initial dual antiplatelet therapy recommendation for MZ at this time can be determined based on the provided evidence.

• The patient, MZ, has been diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) and has undergone percutaneous coronary intervention (PCI) with the deployment of two drug-eluting stents (DES).
• According to the study by 3, prasugrel or ticagrelor plus aspirin should be the dual antiplatelet therapy (DAPT) of choice in patients with acute coronary syndrome (ACS) undergoing PCI, unless they are at particularly high risk of bleeding.
• The study by 4 suggests that a de-escalation strategy from prasugrel or ticagrelor to clopidogrel is associated with lower ischemic and bleeding events, but this study does not provide guidance on the initial DAPT recommendation.
• The study by 5 found that the use of prasugrel or ticagrelor as part of triple antithrombotic therapy was associated with significantly more bleeding compared to clopidogrel, but this study is not directly relevant to MZ's situation as he is not on warfarin.
• The study by 6 found that ticagrelor and prasugrel are increasingly used in patients with chronic coronary syndromes (CCS) undergoing PCI, with similar 1-year efficacy and safety compared to clopidogrel.
• The study by 7 discusses the importance of precision antiplatelet therapy after PCI, including the use of CYP2C19 genotyping to guide the selection of P2Y12 receptor inhibitors, but does not provide specific guidance on the initial DAPT recommendation for MZ.

Recommended Dual Antiplatelet Therapy

Based on the evidence, the most appropriate initial dual antiplatelet therapy recommendation for MZ would be:

• Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 12 months, as this combination is supported by the study by 3 and is a common recommendation for patients with ACS undergoing PCI.
• Alternatively, aspirin 325 mg daily plus prasugrel 5 mg daily for 12 months could also be considered, as prasugrel is also a potent P2Y12 inhibitor that has been shown to be effective in patients with ACS undergoing PCI, as noted in the study by 3.