Can I give aspirin (acetylsalicylic acid) to a patient on Brilinta (ticagrelor) with chest pain?

Aspirin Administration in Patients on Ticagrelor with Chest Pain

Yes, you should give aspirin to a patient on Brilinta (ticagrelor) who presents with chest pain, as aspirin is recommended for suspected acute coronary syndrome regardless of current P2Y12 inhibitor therapy.

Rationale for Aspirin Administration

Aspirin remains a cornerstone of acute coronary syndrome (ACS) management even in patients already on ticagrelor:

• The 2015 American Heart Association guidelines explicitly state that "aspirin should be given as soon as possible to patients with suspected ACS" in the absence of true allergy 1
• Aspirin has been shown to significantly decrease mortality due to myocardial infarction in several large studies 1
• Early aspirin administration (within the first few hours of symptom onset) is associated with reduced mortality compared to delayed administration 1

Dosing Recommendations

When administering aspirin to a patient already on ticagrelor with chest pain:

• The suggested dose is 325 mg (1 adult tablet) or 2-4 low-dose "baby" aspirins (81 mg each), chewed and swallowed 1
• Chewing the aspirin facilitates more rapid absorption in the setting of acute chest pain

Dual Antiplatelet Therapy Considerations

Patients on ticagrelor are typically already on dual antiplatelet therapy (DAPT) with aspirin, but there are important considerations:

• Some patients may be on ticagrelor monotherapy (without daily aspirin) as part of newer treatment strategies 1
• Even if the patient is already on daily low-dose aspirin maintenance therapy, an additional loading dose of aspirin is still appropriate in the acute setting of chest pain
• P2Y12 receptor antagonists (like ticagrelor) in combination with aspirin are recommended for at least 1 year following an ACS 1

Special Considerations and Precautions

While aspirin should be given, be aware of these important considerations:

• Verify the patient has no true aspirin allergy
• Assess for recent significant bleeding, which would be a relative contraindication
• Recognize that dual antiplatelet therapy increases bleeding risk, but this is outweighed by the benefit in the acute setting of chest pain
• If the chest pain is clearly non-cardiac in origin, aspirin administration may be deferred to EMS or physician oversight 1

Management Algorithm

1. Assess if chest pain is likely cardiac in origin (associated symptoms like shortness of breath, nausea, sweating, or radiation to arm/back)
2. Confirm no true aspirin allergy or recent major bleeding
3. Administer 325 mg aspirin (chewed) or 2-4 baby aspirins even if patient is already on ticagrelor
4. Call emergency services immediately
5. Continue other standard ACS management protocols

Remember that early aspirin administration in suspected ACS is a Class I recommendation and has been shown to reduce mortality, making it appropriate even for patients already on P2Y12 inhibitor therapy like ticagrelor.