Aspirin Should Be Added to Ticagrelor for Dual Antiplatelet Therapy
This patient with acute coronary syndrome (elevated troponin I of 102 ng/mL) who underwent percutaneous coronary intervention should receive aspirin (81-100 mg daily) in addition to ticagrelor as dual antiplatelet therapy (DAPT) upon discharge. 1, 2, 3
Rationale for Dual Antiplatelet Therapy
DAPT combining aspirin with a P2Y12 inhibitor (ticagrelor) is the standard of care for all ACS patients after PCI and must be continued for at least 12 months to reduce major adverse cardiovascular events (MACE) and prevent stent thrombosis. 1, 3
The 2025 ACC/AHA/SCAI guidelines provide Class I, Level A evidence that in patients with ACS, an initial oral loading dose of aspirin followed by daily low-dose aspirin is recommended to reduce death and MACE. 1
The same 2025 guidelines state with Class I, Level A evidence that in patients with ACS, an oral P2Y12 inhibitor should be administered in addition to aspirin to reduce MACE. 1
Specific Dosing Recommendations
Aspirin should be dosed at 81-100 mg daily when combined with ticagrelor. 1, 2, 3 This is critical because higher aspirin doses (>100 mg) reduce ticagrelor's effectiveness. 1, 2
The patient should have received a 162-325 mg loading dose of aspirin initially (if not already on aspirin), followed by the 81-100 mg maintenance dose. 1
Ticagrelor dosing is 180 mg loading dose followed by 90 mg twice daily. 1, 2
Duration and Transition Strategy
Standard DAPT duration is 12 months for ACS patients who are not at high bleeding risk. 1, 2, 3
After 1 month of DAPT, if the patient tolerates therapy without bleeding complications, transition to ticagrelor monotherapy (discontinuing aspirin) is a reasonable bleeding reduction strategy. 1, 3 However, this is a Class I recommendation only after at least 1 month of DAPT. 1
Bleeding Risk Mitigation
A proton pump inhibitor (PPI) should be prescribed with DAPT to reduce gastrointestinal bleeding risk. 1, 2, 3 This is particularly important given this patient's comorbidities (hypertension, diabetes). 3
The 2025 guidelines provide Class I, Level A evidence that in patients at high risk of gastrointestinal bleeding, a PPI is recommended in combination with DAPT. 1
Why Not the Other Options?
Option A (No additional medication) is incorrect because discharging a patient on ticagrelor monotherapy immediately after PCI is a critical error—DAPT is mandatory during the first month after stent placement to prevent stent thrombosis. 3
Option C (Clopidogrel) is incorrect because the patient is already on ticagrelor, which is preferred over clopidogrel for ACS patients undergoing PCI. 1, 2 Adding clopidogrel to ticagrelor would be inappropriate and not evidence-based.
Option D (Warfarin) is incorrect because there is no indication for anticoagulation in this patient (no atrial fibrillation, venous thromboembolism, or other indication mentioned). 1
Critical Pitfall to Avoid
The most dangerous error would be discharging this patient without aspirin in the immediate post-PCI period. While aspirin-free strategies with ticagrelor monotherapy may be considered after 1 month, DAPT is essential during the first 3 months after stent placement unless there are life-threatening bleeding concerns. 1, 3
Answer: B. Aspirin