Aspirin is Recommended Upon Discharge
For a patient with acute coronary syndrome who has undergone percutaneous coronary intervention and is started on Brilinta (ticagrelor), aspirin should be administered in addition to ticagrelor as dual antiplatelet therapy (DAPT). 1
Rationale for Dual Antiplatelet Therapy
The standard of care for all ACS patients after PCI requires DAPT combining a P2Y12 inhibitor (in this case, ticagrelor/Brilinta) with aspirin for at least 12 months to reduce major adverse cardiovascular events (MACE) and prevent stent thrombosis. 1
- Aspirin dosing: The patient should receive aspirin 81 mg daily as the maintenance dose when combined with ticagrelor. 1, 2
- Critical dosing consideration: Aspirin doses ≤100 mg daily must be used with ticagrelor, as higher aspirin doses reduce ticagrelor's effectiveness. 1, 2
Why Not the Other Options?
Option A (None): This is incorrect and dangerous. Discontinuing all antiplatelet therapy or using ticagrelor alone immediately after PCI dramatically increases the risk of stent thrombosis and MACE. 1
Option C (Plavix/Clopidogrel): This is incorrect. The patient is already on ticagrelor (Brilinta), which is a more potent P2Y12 inhibitor than clopidogrel. Adding clopidogrel to ticagrelor is not recommended—aspirin is the appropriate second agent for DAPT. 1
Option D (Warfarin): This is incorrect unless the patient has a separate indication for anticoagulation (such as atrial fibrillation or mechanical heart valve), which is not mentioned in this case. 1
Standard DAPT Duration and Strategy
- Default duration: DAPT with ticagrelor plus aspirin should continue for 12 months in patients without high bleeding risk. 1, 3
- Bleeding reduction strategy: After 1 month of DAPT, if the patient has tolerated therapy without bleeding complications, transition to ticagrelor monotherapy (discontinuing aspirin) is a reasonable bleeding reduction strategy. 1, 4, 5
Additional Discharge Recommendations
- Proton pump inhibitor (PPI): Should be prescribed with DAPT to reduce gastrointestinal bleeding risk, especially given the patient's diabetes and hypertension. 1, 3, 2
- Aspirin maintenance dose: Continue 81 mg daily indefinitely after the initial 12-month DAPT period, unless contraindicated. 1
Common Pitfall to Avoid
The most critical error would be discharging this patient on ticagrelor monotherapy immediately after PCI. The first 3 months after stent placement represent the highest risk period for stent thrombosis, and DAPT is mandatory during this time unless there are life-threatening bleeding concerns. 1, 3