How long after receiving a cardiac stent do patients need to take ticagrelor (P2Y12 inhibitor)?

Duration of Ticagrelor Therapy After Cardiac Stent Placement

Patients should receive ticagrelor for at least 12 months after cardiac stent placement for acute coronary syndrome (ACS), while those with stable coronary artery disease should receive it for at least 6 months after drug-eluting stent (DES) implantation. 1

Standard Duration Based on Clinical Presentation

For ACS Patients (NSTEMI, STEMI):

• 12 months of P2Y12 inhibitor therapy (ticagrelor) plus aspirin is the standard recommended duration 1
• Ticagrelor is preferred over clopidogrel for ACS patients due to superior outcomes 1
• Aspirin should be continued indefinitely at a low dose (75-100 mg daily) 1

For Stable Coronary Artery Disease:

• At least 6 months of P2Y12 inhibitor therapy after DES implantation 1
• At least 1 month after bare metal stent (BMS) implantation 1

Adjusting Duration Based on Risk Factors

Extended Duration Considerations:

• Continuation beyond 12 months may be considered in patients who have:
  • Tolerated DAPT without bleeding complications
  • No high bleeding risk (prior bleeding, coagulopathy, oral anticoagulant use)
  • High ischemic risk features 1

Shortened Duration Considerations:

• Discontinuation after 6 months may be reasonable in ACS patients who:
  • Develop high bleeding risk (e.g., need for oral anticoagulation)
  • Are at high risk for severe bleeding complications
  • Develop significant overt bleeding 1

Special Populations

Post-CABG Patients:

• DAPT should be resumed post-operatively as soon as deemed safe after surgery
• Continue until completing the recommended duration (typically 12 months for ACS) 1

Patients Requiring Non-Cardiac Surgery:

• For elective surgery: Consider postponing until completion of minimum DAPT duration
• If surgery cannot be delayed, ticagrelor should be discontinued at least 3 days before surgery 1, 2
• Maintain aspirin perioperatively if bleeding risk allows 2
• Resume P2Y12 inhibitor as soon as possible after surgery (ideally within 24-48 hours) 2

Emerging Evidence

Recent studies suggest potential benefits of shorter DAPT followed by ticagrelor monotherapy:

• The T-PASS trial showed that stopping aspirin within 1 month for ticagrelor monotherapy was non-inferior and even superior to 12-month DAPT, primarily due to reduced major bleeding 3, 4
• However, these newer strategies are not yet incorporated into major guidelines and should be considered investigational

Common Pitfalls to Avoid

• Premature discontinuation: Stopping DAPT too early significantly increases the risk of stent thrombosis, which carries a 40% risk of myocardial infarction or death 2
• Unnecessary prolongation: Continuing DAPT beyond recommended duration without clear indication increases bleeding risk 2
• Failure to reassess risk: Both bleeding and ischemic risks can change over time and should be periodically reassessed 2
• Discontinuing both agents simultaneously: Never stop both antiplatelet agents at the same time in the first months after stenting unless absolutely necessary 2

Remember that the decision to continue or discontinue ticagrelor therapy should always balance the risk of ischemic events against the risk of bleeding complications, with mortality, morbidity, and quality of life as the primary considerations.