From the Research
For patients with Wellens syndrome, a high-risk ECG pattern indicating critical LAD stenosis, switching from aspirin plus clopidogrel to aspirin plus ticagrelor is generally recommended when the patient is diagnosed with acute coronary syndrome (ACS), as supported by the most recent and highest quality study 1.
Key Considerations
- The standard approach would be to administer a loading dose of ticagrelor 180 mg followed by 90 mg twice daily, while continuing aspirin 81 mg daily, as ticagrelor provides more rapid, potent, and consistent platelet inhibition compared to clopidogrel 2.
- This switch should occur as soon as possible after diagnosis, ideally before or immediately after coronary angiography, with no washout period required when switching from clopidogrel to ticagrelor 3.
- Ticagrelor is preferred over clopidogrel in ACS because it translates to better clinical outcomes, including reduced cardiovascular mortality, although it is associated with increased non-CABG-related bleeding risk and dyspnea 4.
Important Contraindications and Precautions
- Contraindications include history of intracranial hemorrhage, active pathological bleeding, severe hepatic impairment, and concomitant use of strong CYP3A inhibitors or inducers 2.
- Patients should be counseled to take ticagrelor exactly as prescribed and not to discontinue without consulting their physician due to the high risk of stent thrombosis or recurrent cardiac events 5.
Clinical Decision Making
- The decision to switch from aspirin plus clopidogrel to aspirin plus ticagrelor should be based on individual patient characteristics, including the risk of bleeding and myocardial ischemia, as well as the potential benefits of more potent platelet inhibition 1.
- Clinicians should carefully weigh the benefits and risks of ticagrelor therapy and consider alternative strategies, such as switching to prasugrel or using a shorter duration of dual antiplatelet therapy, in patients with high bleeding risk or other contraindications 4.