What is the recommended dual antiplatelet therapy (DAPT) regimen, including Brilinta (ticagrelor) or Prasugrel, post Percutaneous Coronary Intervention (PCI) placement?

Dual Antiplatelet Therapy Selection Post-PCI: Ticagrelor vs. Prasugrel

For patients with acute coronary syndrome (ACS) undergoing PCI, ticagrelor is recommended as the first-line P2Y12 inhibitor over clopidogrel, while prasugrel is preferred for P2Y12 inhibitor-naïve patients with ACS undergoing PCI who don't have high bleeding risk or contraindications. 1

P2Y12 Inhibitor Selection Algorithm Post-PCI

For ACS Patients:

1. First-line options:

   • Ticagrelor (180 mg loading, 90 mg twice daily) - recommended for all ACS patients regardless of initial treatment strategy 1
   • Prasugrel (60 mg loading, 10 mg daily) - recommended for P2Y12 inhibitor-naïve patients with ACS undergoing PCI 1

2. When to choose prasugrel:

   • P2Y12 inhibitor-naïve patients
   • No history of stroke/TIA (absolute contraindication) 1, 2
   • Age <75 years (generally) 2
   • Weight ≥60 kg 2
   • Low bleeding risk 1

3. When to choose ticagrelor:

   • All ACS patients without contraindications
   • Patients previously on clopidogrel (should switch to ticagrelor) 1
   • Patients with higher bleeding risk but requiring potent platelet inhibition 1

4. When to use clopidogrel instead:

   • Patients who cannot receive ticagrelor or prasugrel due to:
     • Prior intracranial bleeding
     • Need for oral anticoagulation
     • High bleeding risk
     • Contraindications to more potent agents 1

For Stable CAD Patients:

• Clopidogrel is the standard P2Y12 inhibitor for stable CAD patients undergoing PCI 1, 3

Duration of DAPT

1. ACS patients with PCI:

   • Standard duration: 12 months of DAPT (P2Y12 inhibitor + aspirin) 1
   • High bleeding risk (PRECISE-DAPT ≥25): Consider shorter duration (6 months) 1

2. Stable CAD patients with PCI:

   • Standard duration: 6 months of DAPT 1
   • High bleeding risk: Consider 1-3 months 1

Important Considerations

• Aspirin dosing: Use low-dose aspirin (75-100 mg daily) with all P2Y12 inhibitors 1
• Proton pump inhibitor: Recommended with DAPT to reduce gastrointestinal bleeding risk 1
• Contraindications to prasugrel: 2
  • History of stroke or TIA (absolute)
  • Age ≥75 years (relative, use with caution)
  • Weight <60 kg (consider 5 mg daily dose)
• Contraindications to ticagrelor:
  • Previous intracranial hemorrhage
  • Active bleeding

Special Situations

• Oral anticoagulation needed: Clopidogrel is preferred over ticagrelor or prasugrel 3
• Planned surgery: Discontinue ticagrelor ≥5 days and prasugrel ≥7 days before surgery 3, 2
• Switching from clopidogrel to ticagrelor: Give 180 mg loading dose of ticagrelor regardless of timing and dose of clopidogrel 1

Recent Evidence

While meta-analyses have shown no significant differences in major adverse cardiovascular events or bleeding between prasugrel and ticagrelor in ACS patients undergoing PCI 4, individual patient characteristics should guide selection. The ISAR-REACT-5 trial suggested prasugrel may reduce rates of death, MI, or stroke compared to ticagrelor in ACS patients undergoing PCI without significant differences in bleeding 5.

Recent evidence suggests that patients with high PRECISE-DAPT scores (≥25) may paradoxically have better outcomes with prasugrel than ticagrelor 6, though this finding requires validation in larger studies.