Dual Antiplatelet Therapy Post-PCI for Acute Coronary Syndrome
This patient should receive aspirin (Option B) in addition to ticagrelor upon discharge. 1
Rationale for Dual Antiplatelet Therapy
The standard of care for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) is dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor for at least 12 months. 1 This patient presented with elevated troponin (102 ng/mL, significantly above normal 0.04 ng/mL) indicating myocardial injury, underwent PCI with presumed stent placement, and is already on ticagrelor—therefore aspirin must be added to complete the DAPT regimen. 1, 2
Aspirin Dosing Specifications
- Maintenance dose: 81 mg daily is the preferred dose when combined with ticagrelor 1
- The 2025 ACC/AHA guidelines specifically emphasize that aspirin doses ≤100 mg daily should always be used with ticagrelor, as higher doses do not improve efficacy but increase bleeding risk 1
- This low-dose aspirin should be continued for the full 12-month DAPT duration in standard-risk patients 1, 2
Why Not the Other Options?
Option A (No additional medication) is incorrect because omitting aspirin would leave the patient on ticagrelor monotherapy immediately post-PCI, which is only appropriate after 1-3 months of DAPT in highly selected patients at high bleeding risk. 1 The 2025 ACC/AHA guidelines make clear that DAPT with aspirin and a P2Y12 inhibitor is the default strategy for at least 12 months post-ACS. 1
Option C (Clopidogrel) is incorrect because adding clopidogrel to ticagrelor would create dual P2Y12 inhibition, which is not recommended and has no supporting evidence. 1 The patient is already appropriately on ticagrelor, which is preferred over clopidogrel for ACS patients undergoing PCI. 1
Option D (Warfarin) is incorrect because this patient has no indication for anticoagulation (no atrial fibrillation, venous thromboembolism, or mechanical valve mentioned). 1, 3 Adding warfarin to DAPT creates "triple therapy" with substantially increased bleeding risk and should only be used when a clear anticoagulation indication exists. 1, 3
Duration and Monitoring Considerations
- Continue aspirin indefinitely after the initial 12-month DAPT period 1, 2
- Ticagrelor should be continued for at least 12 months post-PCI 1, 2
- After 1 month of DAPT, transition to ticagrelor monotherapy (discontinuing aspirin) is reasonable only in patients at high bleeding risk, which this patient does not appear to be 1
Bleeding Risk Mitigation
Add a proton pump inhibitor to reduce gastrointestinal bleeding risk given the combination of antiplatelet agents, particularly important in this elderly patient with diabetes. 3, 2, 4