What is the recommended duration of ticagrelor (Brillinta) therapy after drug-eluting stent (DES) placement?

Recommended Duration of Ticagrelor (Brillinta) After Drug-Eluting Stent Placement

In patients who receive a drug-eluting stent (DES), ticagrelor should be given for at least 12 months if placed for acute coronary syndrome (ACS), and for at least 6 months if placed for stable ischemic heart disease (SIHD). 1

Duration Based on Clinical Presentation

For ACS Patients (NSTE-ACS or STEMI)

• Ticagrelor 90 mg twice daily should be given for at least 12 months after DES implantation 1
• Ticagrelor is preferred over clopidogrel for maintenance P2Y12 inhibitor therapy in ACS patients 1
• Daily aspirin dose of 81 mg (range 75-100 mg) should be continued indefinitely 1
• For patients who have tolerated DAPT without bleeding complications and are not at high bleeding risk, continuation of ticagrelor beyond 12 months may be reasonable 1

For SIHD Patients

• P2Y12 inhibitor therapy (typically clopidogrel) should be given for at least 6 months after DES implantation 1, 2
• Daily aspirin dose of 81 mg (range 75-100 mg) should be continued indefinitely 1
• Continuation of DAPT beyond 6 months may be reasonable in patients who have tolerated therapy without bleeding complications and are not at high bleeding risk 1

Special Considerations for Early Discontinuation

High Bleeding Risk Scenarios

• In ACS patients with DES who develop high bleeding risk (e.g., need for oral anticoagulation) or significant bleeding, discontinuation of ticagrelor after 6 months may be reasonable 1
• In SIHD patients with DES who develop high bleeding risk, discontinuation of P2Y12 inhibitor therapy after 3 months may be reasonable 1
• If the risk of morbidity from bleeding outweighs the anticipated benefit of the recommended duration, earlier discontinuation of P2Y12 inhibitor therapy is reasonable 1

Emerging Evidence on Ticagrelor Monotherapy

Recent research suggests potential benefits of de-escalation strategies:

• The TWILIGHT study showed that in high-risk patients who completed 3 months of DAPT after coronary angioplasty, ticagrelor monotherapy (without aspirin) was associated with a 44% reduction in clinically relevant bleeding without increasing ischemic risk 3
• A 2024 individual patient-level meta-analysis demonstrated that de-escalation to ticagrelor monotherapy after short-term DAPT (2 weeks to 3 months) was non-inferior to 12-month DAPT for major adverse cardiovascular events and superior for reducing bleeding risk 4
• The T-PASS trial found that stopping aspirin within 1 month after DES implantation for ACS in favor of ticagrelor monotherapy was both non-inferior and superior to 12-month DAPT for composite outcomes, primarily due to significant reduction in major bleeding 5

Important Counseling Points

• Patients should be counseled on the importance of compliance with antiplatelet therapy 1, 2
• Therapy should not be discontinued before discussion with their cardiologist 1, 2
• The risk of stent thrombosis is highest in the first days to weeks after implantation, making adherence particularly crucial during this period 2

Common Pitfalls and Caveats

• Prasugrel should not be administered to patients with a prior history of stroke or TIA 1
• Proton pump inhibitors should be used in patients with a history of gastrointestinal bleeding who require DAPT 1, 2
• Routine use of proton pump inhibitors is not recommended for patients at low risk of gastrointestinal bleeding 1, 2
• Genetic testing for clopidogrel metabolism is not routinely recommended but might be considered in high-risk patients 1

Remember that the decision regarding the optimal duration of ticagrelor therapy must balance the risk of ischemic events (including stent thrombosis) against the risk of bleeding complications based on individual patient factors 1.