Why would a patient with Coronary Artery Disease (CAD) who had a ST-Elevation Myocardial Infarction (STEMI) need Brilinta (ticagrelor) after stent placement?

Why Brilinta (Ticagrelor) is Essential After STEMI with Three Stents

A patient with STEMI and three stents requires Brilinta (ticagrelor) as part of dual antiplatelet therapy (DAPT) for 12 months because ticagrelor is superior to clopidogrel in reducing cardiovascular death and stent thrombosis in acute coronary syndrome patients, and the default DAPT duration for all STEMI patients is 12 months regardless of revascularization strategy. 1

Primary Rationale: Superior Efficacy in STEMI

Ticagrelor is specifically recommended over clopidogrel for all ACS patients including STEMI because it provides:

• Stronger and more consistent platelet inhibition compared to clopidogrel, which is critical after STEMI when the thrombotic risk is highest 1, 2
• Improved coronary microcirculation with faster blood flow (lower corrected TIMI frame count) and better myocardial perfusion compared to clopidogrel in STEMI patients 2
• Reduced cardiovascular mortality demonstrated in the PLATO trial, with consistent benefits across all ACS presentations including STEMI 3

The 12-Month DAPT Requirement

The European Society of Cardiology mandates 12 months of DAPT (aspirin plus ticagrelor) as the default duration for all STEMI patients, regardless of whether they received medical therapy, PCI, or CABG. 1, 4

This duration applies because:

• STEMI is an acute coronary syndrome, which automatically triggers the 12-month DAPT recommendation 1, 4
• The stent type does not determine DAPT duration - the clinical presentation (STEMI) is what matters 1
• Three stents represent complex PCI, which further supports prolonged DAPT to prevent stent thrombosis 4

Specific Dosing for This Patient

The recommended regimen is:

• Ticagrelor 180 mg loading dose at the time of STEMI presentation 1
• Ticagrelor 90 mg twice daily for maintenance therapy through 12 months 1
• Aspirin 75-100 mg daily continued indefinitely 1

Prevention of Stent Thrombosis

With three stents placed, this patient faces elevated thrombotic risk:

• Multiple overlapping stents increase the risk of stent thrombosis, making potent P2Y12 inhibition with ticagrelor essential 1
• Premature discontinuation of DAPT is the strongest predictor of stent thrombosis and mortality, particularly in the first 12 months 1
• Ticagrelor monotherapy after 3 months of DAPT has been studied in STEMI patients and shows lower bleeding without increased ischemic events, but this is not yet standard practice outside of Asian populations 5, 6

Important Caveats and Bleeding Risk Management

If this patient develops significant bleeding during the 12-month period:

• Consider shortening DAPT to 6 months minimum rather than stopping entirely, as patients with high bleeding risk can safely discontinue the P2Y12 inhibitor at 6 months 1, 4
• Add a proton pump inhibitor (PPI) if the patient has risk factors for gastrointestinal bleeding (age ≥65, history of GI bleeding, or chronic NSAID use) 1
• Never discontinue both antiplatelet agents shortly after PCI unless bleeding is life-threatening and cannot be controlled 1

Beyond 12 Months: Extended DAPT Consideration

After completing 12 months of DAPT without bleeding complications, this patient may be considered for extended therapy:

• Ticagrelor 60 mg twice daily (reduced dose) plus aspirin may be continued for up to 3 years in high ischemic-risk patients who tolerated DAPT well 1
• High ischemic-risk features include: age ≥65 years, diabetes on medication, prior spontaneous MI, multivessel CAD, or chronic kidney disease 1
• The decision to extend beyond 12 months should be reassessed at the 12-month mark based on bleeding tolerance and ongoing ischemic risk 1, 4

Common Pitfalls to Avoid

• Do not use clopidogrel instead of ticagrelor unless ticagrelor is contraindicated or not available - this represents suboptimal therapy for STEMI 1
• Do not stop DAPT at 6 months simply because newer-generation drug-eluting stents were used - STEMI mandates 12 months regardless of stent type 1
• Do not perform platelet function testing to guide dose adjustments - this is not recommended and can lead to inappropriate de-escalation 1