From the Guidelines
The most appropriate oral antiplatelet therapy regimen for BA at this time is aspirin 81 mg daily plus ticagrelor 90 mg twice daily for at least 6-12 months, followed by aspirin 81 mg daily indefinitely. This dual antiplatelet therapy (DAPT) is recommended following drug-eluting stent placement to prevent stent thrombosis and future cardiovascular events, as supported by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. Ticagrelor is preferred over clopidogrel in this case due to its more predictable antiplatelet effect and superior outcomes in acute coronary syndrome, as noted in the 2019 ESC/EACTS guidelines on myocardial revascularization 1. Prasugrel would not be appropriate for BA given her advanced age (73 years) and low body weight (62 kg), which increase her bleeding risk with this medication, as indicated in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. The duration of DAPT should be individualized based on her bleeding risk versus ischemic risk, but generally 6-12 months is recommended after DES placement, as stated in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. After completing the DAPT period, lifelong low-dose aspirin therapy is indicated for secondary prevention, as recommended in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. BA's chronic kidney disease should be monitored during antiplatelet therapy, but her current renal function does not contraindicate this regimen. Key considerations in selecting the antiplatelet regimen include:
- The type of stent used (in this case, drug-eluting stents)
- The patient's risk of bleeding and ischemic events
- The patient's ability to tolerate and comply with the recommended therapy
- The need for lifelong aspirin therapy after completion of the DAPT period.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Initiate treatment with a single 60 mg oral loading dose (2). Continue at 10 mg once daily with or without food. Consider 5 mg once daily for patients <60 kg (2). Patients should also take aspirin (75 mg to 325 mg) daily (2). The most appropriate oral antiplatelet therapy regimen to recommend for BA at this time is Aspirin 81 mg daily plus prasugrel 10 mg daily for a certain period, but the exact duration is not directly stated in the provided drug label. However, considering BA's weight is 62 kg, which is close to the 60 kg threshold, and her age (73 years), caution should be exercised.
- The label suggests considering a dose of 5 mg once daily for patients <60 kg 2.
- It is also noted that in patients ≥75 years of age, prasugrel is generally not recommended, except in high-risk patients (diabetes or prior myocardial infarction [MI]), where its use may be considered 2. Given these considerations and the fact that BA has undergone bifurcation stenting, the decision on the exact duration and dosage of prasugrel should be made with caution, taking into account her specific risk factors and clinical presentation.
From the Research
Oral Antiplatelet Therapy Regimen
The most appropriate oral antiplatelet therapy regimen for BA can be determined based on the provided evidence.
- The study 3 recommends aspirin for all patients with suspected acute coronary syndrome (ACS) unless contraindicated, and the addition of a second antiplatelet (e.g., clopidogrel, ticagrelor, or prasugrel) for most patients.
- The study 4 suggests that aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-percutaneous coronary intervention patients with ACS.
- The study 5 found that ticagrelor was associated with a significantly lower risk of major adverse cardiovascular events (MACE) and all-cause hospitalization compared with clopidogrel after PCI for ACS.
- The study 6 compared the antiplatelet action of ticagrelor with prasugrel in ACS patients with high on-clopidogrel platelet reactivity following PCI and found that ticagrelor produces a significantly higher platelet inhibition compared with prasugrel.
Recommended Regimen
Based on the evidence, the most appropriate oral antiplatelet therapy regimen for BA would be:
- Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 3 months, then aspirin 81 mg daily plus clopidogrel 75 mg daily indefinitely, or
- Aspirin 81 mg daily plus ticagrelor 90 mg twice daily for 3 months, then ticagrelor 90 mg twice daily indefinitely, as the study 4 and 5 suggest the benefits of ticagrelor in reducing MACE and hospitalization.