Can Brillinta (ticagrelor) be used in patients with a Watchman device?

From the Guidelines

Brilinta (ticagrelor) can be used in patients with a Watchman device, as part of a dual antiplatelet therapy (DAPT) regimen, which typically includes aspirin and a P2Y12 inhibitor like ticagrelor, for a period of 1-6 months after implantation. The use of ticagrelor in this context is supported by the most recent guidelines, including the 2019 AHA/ACC/HRS focused update on the management of patients with atrial fibrillation 1. This update highlights the importance of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, and ticagrelor is considered a suitable option for DAPT in these patients.

Key Considerations

• The standard post-Watchman anticoagulation protocol often includes aspirin 81-325 mg daily indefinitely, combined with either clopidogrel, ticagrelor, or another P2Y12 inhibitor for 1-6 months after implantation.
• For patients who cannot tolerate warfarin or direct oral anticoagulants, a DAPT regimen including ticagrelor may be particularly appropriate.
• The dosing for ticagrelor is typically 90 mg twice daily.
• Ticagrelor works by reversibly binding to P2Y12 receptors on platelets, preventing platelet activation and aggregation, which helps prevent thrombus formation on the Watchman device while endothelialization occurs.
• Patients should be monitored for bleeding complications, and medication adjustments may be necessary based on individual risk factors and response to therapy.

Evidence Summary

The evidence supporting the use of ticagrelor in patients with a Watchman device is based on studies such as the 2019 AHA/ACC/HRS focused update 1 and the 2018 North American perspective on antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention 1. These studies highlight the importance of antithrombotic therapy in patients with atrial fibrillation and the role of ticagrelor as a suitable option for DAPT in these patients. Additionally, the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation provides information on the use of percutaneous approaches to occlude the left atrial appendage, including the Watchman device 1.

From the Research

Brillinta (Ticagrelor) and Watchman Device

• The use of Brillinta (ticagrelor) in patients with a Watchman device is not directly addressed in the provided studies.
• However, the studies discuss the use of anticoagulants and antiplatelet therapy in patients with a Watchman device 2, 3, 4, 5, 6.
• The WATCHMAN device is used to prevent stroke and systemic embolization in patients with non-valvular atrial fibrillation, and anticoagulation therapy is typically used after implantation to prevent device-related thrombosis 2, 3.
• The studies suggest that dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, or aspirin and ticagrelor, may be used in patients with a high bleeding risk or contraindication to oral anticoagulation 2, 4, 6.
• However, there is limited evidence on the use of ticagrelor specifically in patients with a Watchman device, and more research is needed to determine the optimal antithrombotic regimen for these patients 2, 3.

Antithrombotic Regimens

• The studies discuss various antithrombotic regimens used in patients with a Watchman device, including:

• Warfarin and aspirin for 45 days after implantation, followed by aspirin and clopidogrel for six months, and then aspirin indefinitely 2.
• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for six months, followed by daily aspirin indefinitely 2, 4.
• Direct oral anticoagulants (DOACs) such as apixaban, which may be used as an alternative to warfarin 3, 5.

• The choice of antithrombotic regimen depends on individual patient factors, such as bleeding risk and contraindication to oral anticoagulation 2, 3, 6.

Device-Related Thrombosis

• Device-related thrombosis is a potential complication of the Watchman device, and can be treated with anticoagulation therapy such as apixaban 5.
• The studies suggest that transesophageal echocardiography (TEE) should be used to assess residual peridevice flow and possible device-related thrombosis at 45 days and 12 months after implantation 3, 5.