What is the most appropriate oral antiplatelet therapy regimen for a 73-year-old female with hypertension, stage 3 chronic kidney disease, osteoporosis, iron-deficiency anemia, and gastroesophageal reflux disease, who has undergone bifurcation stenting with Synergy (everolimus-eluting) drug-eluting stents (DES) for bifurcating stenosis at the proximal left anterior descending (LAD) artery and ostial left circumflex artery?

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 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 reduce the risk of 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 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 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 cautioned against in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. The duration of DAPT should be at least 12 months following complex PCI with bifurcation stenting, as BA received, in line with recommendations from the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 1. After the DAPT period, continuing aspirin monotherapy indefinitely is recommended for secondary prevention, as advised in the 2019 ESC/EACTS guidelines on myocardial revascularization 1. This regimen balances the need for effective platelet inhibition while considering BA's risk factors, including her age, kidney disease, and the complexity of her coronary intervention. Key considerations include the patient's increased risk of bleeding with certain antiplatelet agents, the benefits of ticagrelor in reducing ischemic events, and the importance of long-term aspirin therapy for secondary prevention, as emphasized in the guidelines 1.

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 clopidogrel 75 mg daily. However, according to the prasugrel label, for patients <60 kg, the dose should be 5 mg once daily 2. Since BA weighs 62 kg, she is close to this threshold, but still above 60 kg.

Considering BA's age (73 years) and weight (62 kg), and according to the prasugrel label, prasugrel is generally not recommended in patients ≥75 years of age, except in high-risk patients 2. BA is under 75, but her age and other factors should be taken into consideration when choosing an antiplatelet regimen.

Given the information provided and the drug labels, Aspirin 81 mg daily plus clopidogrel 75 mg daily for 2.5 years, then aspirin 81 mg daily indefinitely seems to be a reasonable choice, but the labels do not provide a direct answer to the question of which regimen is most appropriate for BA. However, the labels do provide guidance on dosing for prasugrel and clopidogrel.

It's also worth noting that the labels for both prasugrel and clopidogrel provide warnings about bleeding risks, and BA's history of iron-deficiency anemia and use of anticoagulants like aspirin should be taken into consideration when choosing an antiplatelet regimen.

• Key considerations:
  • Patient's age and weight
  • History of iron-deficiency anemia
  • Use of anticoagulants like aspirin
  • Bleeding risks associated with prasugrel and clopidogrel
• Recommended regimen: Aspirin 81 mg daily plus clopidogrel 75 mg daily for 2.5 years, then aspirin 81 mg daily indefinitely 3

From the Research

Antiplatelet Therapy Regimen

The most appropriate oral antiplatelet therapy regimen for BA can be determined based on the provided evidence.

• Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated, and the addition of a second antiplatelet is also recommended for most patients 4.
• A study comparing prasugrel and ticagrelor in patients with ACS undergoing PCI found that both agents were associated with similar cardiovascular outcomes and adverse bleeding events 5.
• A network meta-analysis of randomized controlled trials found 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-PCI patients with ACS due to a significantly reduced risk of major adverse cardiovascular events without increasing the risk of bleeding 6.
• Another study found that ticagrelor produces a significantly higher platelet inhibition compared with prasugrel in patients with ACS exhibiting high on-clopidogrel platelet reactivity while on clopidogrel 24 h post-PCI 7.

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, as this regimen has been shown to reduce the risk of major adverse cardiovascular events without increasing the risk of bleeding 6.