What is the recommended duration of ticagrelor therapy for a patient with a drug-eluting stent after angioplasty?

Duration of Ticagrelor After Angioplasty with Drug-Eluting Stent

For patients receiving a drug-eluting stent after angioplasty, ticagrelor combined with aspirin should be continued for at least 12 months, with consideration for extension beyond 12 months in patients who tolerate therapy without bleeding complications and are not at high bleeding risk. 1, 2

Standard Duration Recommendations

Minimum 12-Month Duration

• Both ACC/AHA and ESC guidelines establish 12 months as the default duration of dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin after drug-eluting stent placement, regardless of whether the indication was acute coronary syndrome or stable coronary artery disease. 1, 2
• This 12-month minimum applies to all stent types (drug-eluting or bare metal) when placed in the context of acute coronary syndrome. 1, 2
• Aspirin should be maintained at 81 mg daily (acceptable range 75-100 mg) throughout the DAPT period and continued indefinitely thereafter. 2

For Stable Coronary Artery Disease

• In patients undergoing angioplasty for stable coronary artery disease (not acute coronary syndrome), the default DAPT duration is 6 months after drug-eluting stent implantation according to both ACC/AHA and ESC guidelines. 1
• The ESC guidelines provide slightly more flexibility, suggesting that 1 month of DAPT may be considered in highly selected patients with drug-eluting stents who have very high bleeding risk. 1

Extended Duration Beyond 12 Months

When to Consider Extension

• Extension of ticagrelor-based DAPT beyond 12 months is reasonable (Class IIb recommendation) in patients who have tolerated therapy without bleeding complications and are not at high bleeding risk. 1, 2
• The ESC guidelines specifically recommend ticagrelor preferentially over other P2Y12 inhibitors for extended therapy in patients with prior myocardial infarction. 1
• Patients with complex multivessel disease, left main involvement, or other high ischemic risk features are candidates for extended DAPT. 2

Dose Adjustment for Long-Term Use

• For extended therapy beyond 12 months in patients with prior myocardial infarction, ticagrelor 60 mg twice daily (not the standard 90 mg twice daily dose) is the approved regimen for long-term secondary prevention. 2
• This lower dose maintains efficacy while reducing bleeding risk during prolonged therapy. 2

Shortened Duration Considerations

High Bleeding Risk Patients

• In patients who develop high bleeding risk factors (such as need for oral anticoagulation) or experience significant overt bleeding, discontinuation of ticagrelor after 6 months may be reasonable. 1, 2
• For patients at very high bleeding risk, discontinuation after 3 months may be considered in select cases. 3
• In extremely high-risk bleeding scenarios with drug-eluting stents, discontinuation after 1 month may be considered, though this carries increased thrombotic risk. 1, 3

Timing of Discontinuation Before Surgery

• Before elective coronary artery bypass grafting, ticagrelor should be discontinued at least 3 days prior to surgery to reduce perioperative bleeding risk. 1, 2
• After bypass surgery in patients with acute coronary syndrome or recent stent placement, ticagrelor must be resumed as soon as possible to complete the 12-month DAPT course. 1, 2

Risk Stratification Approach

Assessment Tools

• The ACC/AHA guidelines recommend using the DAPT score to assess the risk-benefit ratio of prolonging DAPT beyond 12 months. 1
• The ESC guidelines recommend using both the DAPT score and PRECISE-DAPT score for comprehensive bleeding and ischemic risk assessment. 1

Decision Algorithm

• Evaluate bleeding risk at baseline and reassess annually: History of gastrointestinal bleeding, need for anticoagulation, advanced age, renal dysfunction, or concurrent use of NSAIDs/steroids indicate higher bleeding risk. 3, 2
• Evaluate ischemic risk: Prior myocardial infarction, diabetes, chronic kidney disease, complex coronary anatomy, history of stent thrombosis, or incomplete revascularization indicate higher ischemic risk. 2
• If low bleeding risk and high ischemic risk: Continue ticagrelor beyond 12 months, consider dose reduction to 60 mg twice daily after the first year. 2
• If high bleeding risk develops: Discontinue ticagrelor at 6 months (or earlier if bleeding occurs) and continue aspirin monotherapy. 1, 2

Critical Caveats and Common Pitfalls

Adherence and Education

• Early discontinuation of ticagrelor within the first 6 months is a major predictor of stent thrombosis and should be avoided except in cases of major bleeding or urgent surgery. 4
• Patients must be counseled that DAPT should not be discontinued without discussion with their cardiologist, as premature cessation dramatically increases thrombotic risk. 3, 2

Proton Pump Inhibitor Co-Administration

• Proton pump inhibitors are recommended (Class I) for all patients on DAPT according to ESC guidelines, and specifically for those with history of gastrointestinal bleeding or increased bleeding risk according to ACC/AHA guidelines. 1, 3
• This reduces gastrointestinal bleeding without compromising antiplatelet efficacy. 3

Aspirin Dosing Error

• Do not use aspirin doses exceeding 100 mg daily when combined with ticagrelor, as higher doses increase bleeding risk without improving efficacy. 2
• The optimal aspirin dose during DAPT is 75-100 mg daily. 2

Automatic Discontinuation at 12 Months

• Do not automatically stop ticagrelor at 12 months in patients who have tolerated therapy well and remain at high ischemic risk, as this increases the risk of late thrombotic events. 2
• Reassess both bleeding and ischemic risk at the 12-month mark before making discontinuation decisions. 2