What is the recommended duration of Brilinta (ticagrelor) therapy after a myocardial infarction (MI)?

Duration of Ticagrelor (Brilinta) Therapy After Myocardial Infarction

After a myocardial infarction (MI), patients should receive dual antiplatelet therapy (DAPT) with ticagrelor and aspirin for at least 12 months, with consideration for extending therapy to 36 months in high-risk patients with low bleeding risk using the 60mg twice daily dose. 1

Standard Duration of DAPT After MI

Initial 12-Month Therapy

• For patients with acute coronary syndrome (ACS) treated with coronary stent implantation (BMS or DES):
  • P2Y12 inhibitor therapy (ticagrelor, prasugrel, or clopidogrel) should be given for at least 12 months 1
  • Ticagrelor is preferred over clopidogrel for maintenance P2Y12 inhibitor therapy in ACS patients 1, 2
  • Daily aspirin dose of 81 mg (range 75-100 mg) should be used in combination 1

For Medically Managed MI (Without Stent)

• In patients with ACS managed with medical therapy alone:
  • P2Y12 inhibitor therapy (ticagrelor or clopidogrel) should be continued for at least 12 months 1
  • Ticagrelor is reasonable to use in preference to clopidogrel 1, 2

Extended DAPT Beyond 12 Months

High Ischemic Risk Patients

For patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, extended therapy may be beneficial:

• Extended Ticagrelor Option: In patients with prior MI 1-3 years previously and high-risk features:
  • Ticagrelor 60mg twice daily (reduced dose) plus aspirin can be continued for up to 36 months 1, 3
  • Greatest benefit seen in patients who either had no interruption or <30 days interruption of P2Y12 therapy 1
  • Provides 1.2-1.3% absolute reduction in ischemic events but 1.2-1.5% increase in major bleeding 1

Patient Selection for Extended Therapy

Consider extended therapy in patients with:

• Multivessel coronary disease (most common indication) 3
• Age >65 years
• Diabetes mellitus
• Second MI
• Chronic kidney disease 3

Early Discontinuation Considerations

High Bleeding Risk Scenarios

• In patients who develop high bleeding risk (e.g., need for oral anticoagulation) or significant overt bleeding:
  • Discontinuation of P2Y12 inhibitor therapy after 6 months may be reasonable in ACS patients with DES 1
  • Continue aspirin indefinitely if possible 1

Perioperative Management

• Discontinue ticagrelor 3-5 days before elective surgery 2
• Resume with loading dose of 180mg within 24 hours after surgery if hemostasis is adequate 2

Special Considerations

Stent Type Considerations

• For drug-eluting stents (DES), minimum DAPT duration is 6 months for stable coronary disease, but 12 months for ACS 1
• Newer generation DES have lower risk of stent thrombosis and may allow for shorter DAPT duration in high bleeding risk patients 2, 4

Bleeding Risk Management

• Add proton pump inhibitor to reduce gastrointestinal bleeding risk 2
• Regularly evaluate bleeding risk during treatment 2
• Consider renal and hepatic function when selecting and dosing antiplatelet agents 2

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping DAPT before recommended duration increases risk of stent thrombosis, MI, and death 2

2. Failure to reduce dose for extended therapy: When extending beyond 12 months, use the lower 60mg twice daily dose of ticagrelor, not the standard 90mg twice daily dose 3

3. Not considering bleeding risk: Extended DAPT provides ischemic benefit at the cost of increased bleeding - always weigh this tradeoff carefully 1

4. Missing the optimal window for extension: The greatest benefit of extended therapy is seen when there is minimal or no interruption in P2Y12 inhibitor therapy 1

In conclusion, while 12 months is the standard duration for DAPT with ticagrelor after MI, extension to 36 months with the reduced dose of 60mg twice daily can be beneficial in selected high-risk patients who have tolerated initial therapy without bleeding complications.