When should Brilinta (ticagrelor) be used post Percutaneous Coronary Intervention (PCI)?

Ticagrelor (Brilinta) Use After Percutaneous Coronary Intervention

Ticagrelor should be used for at least 12 months after PCI in patients with acute coronary syndrome (ACS), while clopidogrel remains the preferred P2Y12 inhibitor for patients undergoing PCI for stable coronary artery disease. 1

Indications for Ticagrelor Post-PCI

ACS Patients (STEMI, NSTEMI, Unstable Angina)

• Ticagrelor 90mg twice daily is recommended for at least 12 months after PCI in ACS patients 1
• Ticagrelor is preferred over clopidogrel in ACS patients due to:
  • Faster onset of action
  • Greater platelet inhibition
  • Reduced composite endpoint of myocardial infarction, stroke, or cardiovascular death 2
• Loading dose: 180mg as early as possible before or at the time of PCI 1
• Maintenance dose: 90mg twice daily 1

Stable Coronary Artery Disease (CCS) Patients

• Clopidogrel is the P2Y12 inhibitor of choice for most patients with stable coronary disease 1
• Ticagrelor may be considered in selected CCS patients at high ischemic/thrombotic risk and low bleeding risk, particularly:
  • Patients with complex PCI (left main, bifurcation requiring 2 stents, suboptimal result) 1
  • Patients with diabetes and prior PCI who have tolerated antiplatelet therapy 3

Duration of Therapy

1. ACS patients: Ticagrelor for at least 12 months 1
2. Stable CAD patients with DES: P2Y12 inhibitor (typically clopidogrel) for at least 12 months if not at high bleeding risk 1
3. Stable CAD patients with BMS: P2Y12 inhibitor for minimum 1 month, ideally up to 12 months 1
4. Patients at high bleeding risk: Consider shorter DAPT duration (1-3 months) followed by P2Y12 inhibitor monotherapy 1

Special Considerations

Patients with Atrial Fibrillation Requiring Anticoagulation

• Clopidogrel is preferred over ticagrelor when triple therapy is needed 1
• Double therapy (OAC + P2Y12 inhibitor) is the default strategy after hospital discharge 1
• Triple therapy duration should be minimized (≤1 month) in most patients 1

Ticagrelor Monotherapy Option

• In high-risk patients who have completed 3 months of DAPT without complications, switching to ticagrelor monotherapy (without aspirin) may be considered to reduce bleeding risk without increasing ischemic events 1, 4
• This strategy may be particularly beneficial in patients with prior MI 4

Important Precautions with Ticagrelor

1. Bleeding risk: Higher non-CABG related bleeding compared to clopidogrel 2
2. Bradyarrhythmias: Can cause ventricular pauses and bradycardia; use with caution in patients with sick sinus syndrome or high-grade AV block 5
3. Dyspnea: Occurs in approximately 14% of patients, usually mild to moderate 2
4. Surgery timing: Discontinue ticagrelor at least 5 days before planned surgery 1
5. Contraindications: History of intracranial hemorrhage, active pathological bleeding, severe hepatic impairment

Common Pitfalls to Avoid

1. Inappropriate switching: Avoid switching between P2Y12 inhibitors without proper loading doses
2. Premature discontinuation: Stopping therapy early significantly increases stent thrombosis risk
3. Missing doses: Ticagrelor's twice-daily dosing requires better adherence than once-daily clopidogrel
4. Ignoring dyspnea: Patients should be counseled that mild dyspnea is common and usually doesn't require discontinuation
5. Overlooking drug interactions: Ticagrelor is metabolized by CYP3A4; avoid strong inhibitors/inducers

Remember that the decision to use ticagrelor must balance the reduced ischemic risk against the increased bleeding risk, especially in patients with prior stroke/TIA where intracranial hemorrhage risk may be higher 1.