What is the recommended duration of treatment with Brilinta (ticagrelor) and Eliquis (apixaban) after receiving a stent in the right coronary artery (RCA)?

Duration of Ticagrelor and Apixaban After RCA Stent

For patients with an RCA stent, the recommended duration of therapy is 12 months of ticagrelor (Brilinta) if presenting with ACS, while apixaban (Eliquis) should be limited to a maximum of 6 months if triple therapy is required, followed by P2Y12 inhibitor plus anticoagulant. 1

Treatment Duration Based on Clinical Presentation

For Acute Coronary Syndrome (ACS) Patients:

• Default DAPT duration: 12 months regardless of stent type (BMS or DES) 1
  • P2Y12 inhibitor options include ticagrelor 90mg twice daily, prasugrel 10mg daily, or clopidogrel 75mg daily 1
  • Ticagrelor is preferred over clopidogrel for maintenance therapy in ACS patients 1
• Shorter duration (6 months) should be considered in high bleeding risk patients 1
• Longer duration (>12 months) may be considered in patients who have tolerated DAPT without bleeding complications 1

For Stable CAD Patients:

• DAPT duration: 1-6 months depending on bleeding risk 1, 2
• For patients receiving DES for non-ACS indications, clopidogrel should be given for at least 12 months if not at high risk of bleeding 1
• For patients receiving BMS for non-ACS indications, clopidogrel should be given for a minimum of 1 month and ideally up to 12 months 1

Special Considerations for Patients on Anticoagulation

If the patient requires oral anticoagulation (like apixaban) in addition to antiplatelet therapy:

• Triple therapy (DAPT + anticoagulant) should be limited to a maximum of 6 months or omitted after hospital discharge 1
• After the initial period of triple therapy, continue with:
  • P2Y12 inhibitor (preferably clopidogrel) plus anticoagulant until 12 months post-PCI 1
  • Then anticoagulant alone after 12 months 1
• Clopidogrel is the P2Y12 inhibitor of choice when triple therapy is required - ticagrelor or prasugrel are not recommended in this setting 1
• Consider a target INR of 2.0-2.5 if warfarin is used 1
• Use low-dose aspirin (≤100 mg daily) 1

Risk Assessment and Individualization

The decision about therapy duration should be guided by:

1. Ischemic risk factors:

   • Prior MI or ACS presentation
   • Multiple stents/complex PCI
   • Diabetes mellitus
   • Left ventricular dysfunction

2. Bleeding risk factors:

   • Advanced age
   • Oral anticoagulation requirement
   • Prior major bleeding
   • Anemia
   • Renal dysfunction

Important Caveats and Pitfalls

• Never discontinue DAPT within the first month after stent placement due to high risk of stent thrombosis 1, 2
• If elective surgery is needed, delay it for at least 1 month after stent placement 1
• Patients should be counseled on the risks of premature DAPT discontinuation before stent placement 1
• The decision on DAPT duration should be based on patient-specific ischemic and bleeding risks rather than stent type 1, 2
• For patients requiring triple therapy, use proton pump inhibitors to reduce gastrointestinal bleeding risk 1, 3
• Recent evidence suggests that discontinuing aspirin rather than the P2Y12 inhibitor may be associated with better outcomes in patients requiring triple therapy, but this approach requires further validation 4, 3

By following these guidelines, clinicians can optimize the balance between preventing ischemic events and minimizing bleeding risk in patients with RCA stents requiring antiplatelet and/or anticoagulant therapy.