Ticagrelor Dosage and Duration in STEMI Patients
For patients with ST-Elevation Myocardial Infarction (STEMI), ticagrelor should be administered at a loading dose of 180 mg followed by 90 mg twice daily for at least 12 months. 1
Initial Dosing and Administration
- A loading dose of 180 mg ticagrelor should be given as early as possible before or at the time of percutaneous coronary intervention (PCI) 1
- Chewing the loading dose rather than swallowing it whole may provide faster platelet inhibition in STEMI patients, with significant reduction in platelet reactivity at 30 minutes post-administration 2
- Following the loading dose, patients should receive a maintenance dose of 90 mg twice daily 1
- Ticagrelor should be administered with a low-dose aspirin (81 mg daily, range 75-100 mg) for optimal dual antiplatelet therapy (DAPT) 1
Duration of Therapy
- Ticagrelor should be continued for at least 12 months in STEMI patients treated with PCI and coronary stent implantation 1
- For STEMI patients treated with medical therapy alone (without revascularization or fibrinolytic therapy), ticagrelor should also be continued for at least 12 months 1
- In patients who have tolerated DAPT without bleeding complications and who are not at high bleeding risk, continuation of ticagrelor beyond 12 months may be reasonable 1, 3
Preference for Ticagrelor Over Other P2Y12 Inhibitors
- In patients with ACS (including STEMI) treated with DAPT after coronary stent implantation, it is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 inhibitor therapy (Class IIa, Level of Evidence: B-R) 1
- Ticagrelor has the advantage of being a direct-acting P2Y12 inhibitor that does not require metabolic activation, unlike clopidogrel and prasugrel 4
- Unlike prasugrel, ticagrelor has a reversible binding mechanism, which may be advantageous if urgent surgery is needed 4
Special Considerations and Contraindications
- Ticagrelor should be discontinued at least 5 days before any planned surgery to reduce bleeding risk 1
- Patients with a history of intracranial bleeding, those requiring oral anticoagulation, or those at high bleeding risk may be better suited for clopidogrel rather than ticagrelor 5
- In patients ≥75 years of age, the bleeding risk with more potent P2Y12 inhibitors like ticagrelor may outweigh the ischemic benefit in some cases 5
- For patients who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy) or significant overt bleeding, discontinuation of ticagrelor after 6 months may be reasonable in ACS patients treated with drug-eluting stents 1
Monitoring and Follow-up
- Regular assessment for bleeding complications is essential during the course of ticagrelor therapy 1
- If the risk of morbidity due to bleeding outweighs the anticipated benefits of ticagrelor therapy, earlier discontinuation should be considered 1
- After the first year of therapy in ACS patients, a reduced dose of ticagrelor (60 mg twice daily) may be considered for extended treatment beyond 12 months 3
By following these evidence-based recommendations for ticagrelor dosing and duration in STEMI patients, clinicians can optimize antiplatelet therapy to reduce ischemic events while managing bleeding risks.