Dual Antiplatelet Therapy for NSTEMI Post-PCI
This patient should receive aspirin (81 mg daily) in addition to ticagrelor upon discharge (Answer B). Dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 inhibitor is the standard of care for all patients with acute coronary syndrome following percutaneous coronary intervention.
Mandatory DAPT After ACS and PCI
In patients with ACS who undergo PCI, DAPT with aspirin plus a P2Y12 inhibitor must be administered for at least 12 months to reduce major adverse cardiovascular events and prevent stent thrombosis. 1 This patient has NSTEMI (evidenced by elevated troponin I at 1024 ng/mL with normal being ≤0.04 ng/mL) and underwent PCI, making DAPT absolutely essential.
- The 2025 ACC/AHA guidelines explicitly state that aspirin should be continued indefinitely after ACS, with an initial loading dose of 162-325 mg followed by daily low-dose maintenance therapy 1
- When combined with ticagrelor specifically, the aspirin maintenance dose must be 81 mg daily (not higher doses), as aspirin doses >100 mg reduce ticagrelor's effectiveness 1
- P2Y12 inhibitor therapy (ticagrelor in this case) should be given for at least 12 months in all post-PCI patients treated with coronary stents 1
Why Not the Other Options
Option A (No additional medication) is incorrect and dangerous. Discharging a patient on ticagrelor monotherapy immediately after PCI represents a critical error, as DAPT is mandatory during the first month after stent placement to prevent stent thrombosis 2. Ticagrelor monotherapy can only be considered after at least 1 month of DAPT in patients who have tolerated therapy without bleeding complications 1.
Option C (Clopidogrel) is incorrect because the patient is already on ticagrelor. Adding clopidogrel to ticagrelor would constitute dual P2Y12 inhibition, which is not standard practice and would dramatically increase bleeding risk without additional benefit 1.
Option D (Warfarin) is incorrect unless there is a specific indication for anticoagulation (such as atrial fibrillation, mechanical heart valve, or venous thromboembolism), which is not mentioned in this case 1. Adding warfarin to DAPT ("triple therapy") significantly increases bleeding risk and should only be used when anticoagulation is absolutely necessary 1.
Additional Discharge Recommendations
A proton pump inhibitor (PPI) should be prescribed with DAPT to reduce gastrointestinal bleeding risk, especially given this patient's comorbidities of hypertension and diabetes 1, 3, 2. This is a Class I recommendation from the 2025 ACC/AHA guidelines 1.
Duration and Future Considerations
- Standard DAPT duration is 12 months for all ACS patients who are not at high bleeding risk 1
- After completing 1 month of DAPT without bleeding complications, transition to ticagrelor monotherapy (discontinuing aspirin) is a reasonable bleeding reduction strategy 1
- However, the initial discharge regimen must include both aspirin and ticagrelor 1, 2