What is the role of Ticagrel (antiplatelet medication) in managing acute coronary syndrome?

Ticagrelor in Acute Coronary Syndrome

Ticagrelor is the preferred P2Y12 inhibitor for patients with acute coronary syndrome, superior to clopidogrel in reducing cardiovascular death, myocardial infarction, and stroke. 1

Dosing and Administration

For ACS patients:

• Loading dose: 180 mg administered as soon as possible 1, 2
• Maintenance dose: 90 mg twice daily for the first 12 months 1, 2
• After 12 months: Transition to 60 mg twice daily for continued secondary prevention 1, 2
• First maintenance dose: Administer 6-12 hours after loading dose 2

Aspirin co-administration:

• Use with aspirin 75-100 mg daily (do not exceed 100 mg) 1, 2
• Higher aspirin doses reduce ticagrelor efficacy 1

Clinical Superiority Over Clopidogrel

The PLATO trial demonstrated ticagrelor's superiority in 18,624 ACS patients: 3

• Reduced primary composite endpoint (cardiovascular death, MI, or stroke) from 11.7% to 9.8% (HR 0.84, P<0.001) 3
• Reduced cardiovascular mortality from 5.1% to 4.0% (P=0.001) 3
• Reduced all-cause mortality from 5.9% to 4.5% (P<0.001) 3
• Reduced myocardial infarction from 6.9% to 5.8% (P=0.005) 3
• Reduced stent thrombosis 1

When to Use Ticagrelor vs. Alternatives

Ticagrelor is recommended as first-line for: 1

• All patients with moderate-to-high risk NSTE-ACS (e.g., elevated troponins) 1
• All patients with STEMI undergoing PCI 1
• Patients managed conservatively without planned invasive evaluation 1
• Patients previously on clopidogrel (switch immediately with 180 mg loading dose) 1

Use prasugrel instead when: 1

• Patient is P2Y12 inhibitor-naïve and undergoing PCI with known coronary anatomy 1
• No contraindications exist (see below) 1

Use clopidogrel instead when: 1

• Ticagrelor or prasugrel are unavailable, not tolerated, or contraindicated 1
• Patient requires oral anticoagulation (clopidogrel preferred due to lower bleeding risk) 1, 4
• High bleeding risk with inability to tolerate potent P2Y12 inhibition 4

Absolute Contraindications

Do not use ticagrelor in patients with: 2

• Previous intracranial hemorrhage 1, 2
• Active pathological bleeding 2

Note: Unlike prasugrel, ticagrelor can be used in patients with prior ischemic stroke or TIA 1, 4

Bleeding Risk Management

Ticagrelor increases non-CABG major bleeding compared to clopidogrel (4.5% vs 3.8%, P=0.03): 3

• More fatal intracranial bleeds (0.1% vs 0.01%, P=0.02) 4
• No difference in overall major bleeding (11.6% vs 11.2%, P=0.43) 3

Strategies to minimize bleeding: 1, 4

• Prescribe proton pump inhibitor with DAPT (Class I recommendation) 1, 4
• Use radial over femoral access for PCI 1, 4
• Maintain aspirin dose at 75-100 mg daily 1, 4
• After 12 months in patients who tolerated DAPT, transition to ticagrelor monotherapy ≥1 month after PCI 1

Duration of Therapy

Standard duration: 1

• 12 months of dual antiplatelet therapy (ticagrelor + aspirin) is the default strategy 1
• Continue beyond 12 months with 60 mg twice daily for extended secondary prevention 1, 2

Shortened duration considerations: 4

• In high bleeding risk patients (PRECISE-DAPT score ≥25), consider 6 months duration 4
• Transition to ticagrelor monotherapy ≥1 month after PCI in patients who tolerated DAPT 1

Perioperative Management

For urgent CABG: 2

• Do not start ticagrelor in patients undergoing urgent CABG 2
• Discontinue ticagrelor at least 5 days before elective surgery 1, 2
• Resume as soon as hemostasis is secure postoperatively 5

Critical timing: 5

• Thrombotic risk is highest in first month after ACS 5
• Do not discontinue DAPT within first month for elective non-cardiac surgery 4
• Postpone elective surgery if <1 month from ACS whenever possible 5

Common Pitfalls to Avoid

Do not: 4, 5

• Use aspirin doses >100 mg daily with ticagrelor 1, 2
• Administer ticagrelor with another oral P2Y12 inhibitor 2
• Stop ticagrelor abruptly (increases risk of stent thrombosis, MI, and death) 2
• Fail to switch from clopidogrel to ticagrelor in ACS patients when indicated 4
• Completely withhold DAPT in post-operative ACS patients due to bleeding concerns 5
• Forget to prescribe PPI with DAPT 1, 4

Non-Hemorrhagic Adverse Effects

Dyspnea: 1, 6

• Occurs in 10-15% of patients 1
• Usually mild to moderate severity 6
• Rarely severe enough to require discontinuation 1, 6

Ventricular pauses: 6

• Largely asymptomatic 6
• Monitor in patients with bradycardia risk 6