Duration of DAPT with Brillinta (Ticagrelor) and Aspirin for In-Stent Restenosis
For patients undergoing angioplasty for in-stent restenosis, dual antiplatelet therapy with aspirin and clopidogrel should be continued for at least 6 months, with strong consideration for extending to 24 months in patients who tolerate DAPT without bleeding complications. 1, 2
Standard Duration Recommendation
Aspirin 81 mg daily (range 75-100 mg) should be continued indefinitely in all patients after treatment for in-stent restenosis 1, 3
A P2Y12 inhibitor (clopidogrel 75 mg daily) should be given for at least 6 months as the minimum duration after angioplasty for in-stent restenosis 1
Clopidogrel is the preferred P2Y12 inhibitor for in-stent restenosis treatment, not ticagrelor or prasugrel 1
Important Clarification About Ticagrelor (Brillinta)
Ticagrelor is NOT the standard P2Y12 inhibitor for in-stent restenosis. The guidelines specifically recommend clopidogrel for this indication 1. Ticagrelor is preferentially recommended for acute coronary syndrome patients undergoing PCI, but in-stent restenosis is typically managed differently unless it presents as ACS 3.
Evidence-Based Duration Strategy
Extended DAPT (Beyond 6 Months)
In patients who tolerate DAPT without bleeding complications and are not at high bleeding risk, continuation beyond 6 months may be reasonable 1, 3
The PRODIGY trial substudy demonstrated significant benefit with 24-month DAPT versus 6-month DAPT in patients treated for in-stent restenosis, showing reduced death and MI (6.5% vs. 15.5%; p=0.03) without increased bleeding 2
The cumulative incidence of death, MI, or stroke at 24 months was 7.3% with long DAPT versus 16.7% with short DAPT (p=0.034), providing the strongest evidence for extended therapy in this specific population 2
Shortened DAPT (Less Than 6 Months)
In patients who develop high bleeding risk (e.g., requiring oral anticoagulation) or significant overt bleeding, discontinuation after 3 months may be reasonable 1, 3
For patients at very high bleeding risk, discontinuation after 1 month may be considered in select cases, though this carries higher ischemic risk 1
Risk Stratification Algorithm
Factors Favoring Extended DAPT (12-24 months):
- No bleeding complications during initial 6 months 1, 2
- Low bleeding risk (PRECISE-DAPT score <25) 3
- High ischemic risk (diabetes, multivessel disease, prior MI, complex lesions) 3
- Good medication adherence 1
Factors Favoring Shortened DAPT (3-6 months):
- High bleeding risk (PRECISE-DAPT score ≥25) 3
- Need for oral anticoagulation 3, 1
- History of gastrointestinal bleeding 3
- Advanced age with frailty 3
- Planned major surgery 3
Critical Pitfalls to Avoid
The risk of stent thrombosis is highest in the first days to weeks after stent implantation, making DAPT adherence particularly crucial during the initial period 1
Never discontinue DAPT before discussing with the treating cardiologist, as premature cessation is associated with catastrophic stent thrombosis 3
Do not use prasugrel in patients with prior stroke or TIA (Class III recommendation) 3
Gastrointestinal Protection
Proton pump inhibitors (PPIs) should be used in patients with history of gastrointestinal bleeding who require DAPT 3, 1
PPIs are reasonable in patients with increased bleeding risk (advanced age, concomitant warfarin, steroids, NSAIDs, H. pylori infection) 3, 1
Context-Specific Modifications
If the in-stent restenosis presented as an acute coronary syndrome, then the standard ACS DAPT duration applies: 12 months of DAPT with ticagrelor or prasugrel preferred over clopidogrel 3. However, for elective treatment of in-stent restenosis discovered on surveillance or stable symptoms, clopidogrel for 6-24 months is the evidence-based approach 1, 2.