Recommended Dosing of Ticagrelor Post-Myocardial Infarction
The recommended dose of ticagrelor post-myocardial infarction is 90 mg twice daily for the first 12 months, followed by 60 mg twice daily for extended therapy beyond 12 months in high-risk patients. 1
Initial 12 Months Post-MI Therapy
Loading Dose
- Initial loading dose: 180 mg given as early as possible or at the time of primary PCI 1
Maintenance Dose (First 12 Months)
- 90 mg twice daily for 12 months 1
- Must be administered with low-dose aspirin (81 mg daily is the preferred maintenance dose) 1
Extended Therapy (Beyond 12 Months)
For patients with prior MI who have completed the initial 12-month DAPT course and remain at high risk for atherothrombotic events:
- 60 mg twice daily is the recommended dose for long-term secondary prevention 1
- This lower dose (60 mg twice daily) demonstrated similar efficacy to the 90 mg dose with a more favorable benefit/risk ratio in the PEGASUS-TIMI 54 trial 1, 2
- The 60 mg twice-daily dose achieved high levels of platelet inhibition similar to the 90 mg dose 3
Patient Selection for Extended Therapy
Extended therapy with ticagrelor 60 mg twice daily should be considered for patients with:
- Prior MI (1-3 years previously)
- Additional high-risk features such as:
- Age ≥65 years
- Diabetes mellitus
- Multivessel coronary disease
- Chronic kidney disease
- Prior PCI or additional MI
- DAPT score ≥2 1
Important Precautions
- Contraindications: Avoid in patients with active pathological bleeding, history of intracranial hemorrhage, or ongoing bleeds 4
- Discontinuation: Stop ticagrelor at least 5 days before any planned surgery 1
- Monitoring: Observe for bleeding complications, dyspnea, bradycardia, and ventricular pauses 4
- Drug Interactions: Use caution with strong CYP3A4 inhibitors or inducers 4
Efficacy and Safety Considerations
- Ticagrelor 90 mg twice daily demonstrated superior efficacy compared to clopidogrel in reducing cardiovascular mortality, MI, and stroke in the PLATO trial 4
- For long-term therapy (>12 months), the 60 mg twice-daily dose reduced the risk of cardiovascular death, MI, or stroke compared to placebo (7.77% vs. 9.04%) 2
- TIMI major bleeding was higher with ticagrelor 60 mg compared to placebo (2.30% vs. 1.06%) 2
- Patients with peripheral artery disease and prior MI derived particularly large absolute benefits from extended ticagrelor therapy 5
Clinical Pearl
When switching from clopidogrel to ticagrelor, patients should receive the full 180 mg loading dose regardless of prior clopidogrel therapy, and clopidogrel should be discontinued when ticagrelor is started 4.