Can ticagrelor (Brillinta) be used instead of clopidogrel (Plavix) for patients undergoing Transcatheter Aortic Valve Replacement (TAVR)?

Can Ticagrelor (Brillinta) Be Used Instead of Clopidogrel (Plavix) for TAVR?

No, ticagrelor should not be used as standard antiplatelet therapy after TAVR; clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily is the recommended regimen based on guideline recommendations. 1

Guideline-Based Standard of Care

The established antithrombotic regimen after TAVR is:

• Clopidogrel 75 mg daily for 3-6 months (Class IIb recommendation) 1
• Plus aspirin 75-100 mg daily lifelong 1
• This recommendation stems from the protocols used in pivotal TAVR clinical trials, though the specific antiplatelet regimen itself was never formally tested 1

Why Ticagrelor Is Not Recommended

The use of ticagrelor as part of triple antithrombotic therapy (with aspirin and anticoagulation) is explicitly not recommended in patients requiring oral anticoagulation after TAVR. 1 The European Society of Cardiology states that "the use of ticagrelor or prasugrel as part of TAT [triple antithrombotic therapy] is not recommended." 1

For patients requiring anticoagulation plus antiplatelet therapy, clopidogrel is specifically preferred over ticagrelor due to higher bleeding risk with ticagrelor. 1 The 2022 Circulation guidelines note that "the initial antiplatelet of choice in patients receiving anticoagulation during ACS is clopidogrel due to higher risk of bleeding associated with ticagrelor versus clopidogrel." 1

Limited Evidence for Ticagrelor in TAVR

While one small study (REAC-TAVI trial, n=68) showed ticagrelor achieved better platelet inhibition than clopidogrel in TAVR patients with high platelet reactivity, this was a mechanistic study focused on platelet function testing, not clinical outcomes like mortality, stroke, or bleeding. 2 The study demonstrated 100% of ticagrelor patients achieved adequate platelet suppression versus only 21% with clopidogrel, but this surrogate endpoint does not translate to guideline-level evidence for routine use. 2

Special Circumstances

For patients with atrial fibrillation or other indications for anticoagulation after TAVR:

• Anticoagulation should be given as per guidelines for AF in patients with prosthetic valves 1
• After a short period (up to 1 week) of triple therapy, dual antithrombotic therapy (anticoagulant plus clopidogrel) is recommended 1
• Ticagrelor may only be considered in exceptional cases with very high stent thrombosis risk, but this is not standard for TAVR 1

For patients with recent coronary stenting:

• Clopidogrel remains the preferred P2Y12 inhibitor when combined with anticoagulation 1
• Ticagrelor might be considered only in patients at exceptionally high risk for stent thrombosis where benefits outweigh bleeding risks 1

Common Pitfalls to Avoid

• Do not extrapolate ACS data to TAVR: Ticagrelor's superiority in acute coronary syndromes does not apply to the TAVR population, which has different thrombotic and bleeding risk profiles 1
• Avoid triple therapy with ticagrelor: If anticoagulation is needed, never use ticagrelor as part of triple therapy due to excessive bleeding risk 1
• Consider bleeding risk: TAVR patients are typically elderly with multiple comorbidities and higher baseline bleeding risk; more potent antiplatelet agents increase this risk without proven benefit 1, 3

Emerging Evidence on Antiplatelet Therapy Post-TAVR

Recent meta-analyses suggest that even dual antiplatelet therapy (aspirin plus clopidogrel) may not be superior to single antiplatelet therapy (aspirin alone) after TAVR. 3, 4, 5 Studies show DAPT is associated with increased major bleeding (OR 2.29) without reducing stroke or mortality compared to aspirin alone. 4, 5 This further argues against using an even more potent agent like ticagrelor.