In a patient with coronary artery disease who has received a drug‑eluting stent, how long should ticagrelor (Brilinta) be continued?

Duration of Ticagrelor (Brilinta) After Drug-Eluting Stent in CAD

For patients with coronary artery disease who received drug-eluting stents for acute coronary syndrome, ticagrelor should be continued for at least 12 months; for stable coronary disease, at least 6 months is required. 1, 2

Standard Duration Based on Clinical Presentation

Acute Coronary Syndrome (ACS)

• Ticagrelor 90 mg twice daily must be continued for a minimum of 12 months after DES implantation 1, 2
• This 12-month recommendation applies regardless of stent type (bare metal or drug-eluting) 1
• Ticagrelor is preferred over clopidogrel for maintenance therapy in ACS patients 1, 2
• Aspirin 81 mg daily (range 75-100 mg) should be continued alongside ticagrelor 1, 2

Stable Ischemic Heart Disease (SIHD)

• Minimum duration is 6 months after DES implantation 1, 2
• Some guidelines suggest 1-6 months depending on bleeding risk, with 6 months being standard for patients without high bleeding risk 1
• Aspirin 81 mg daily should be maintained indefinitely 1, 2

Extension Beyond Standard Duration

When to Consider Prolonged Therapy (>12 months)

Continuation beyond 12 months may be reasonable if ALL of the following criteria are met: 1, 2, 3

• Patient has tolerated DAPT without any bleeding complications during the initial 12 months
• Patient is NOT at high bleeding risk (no prior bleeding on DAPT, no coagulopathy, no oral anticoagulant use)
• Patient has not experienced significant overt bleeding

For extended therapy beyond 12 months, consider reducing ticagrelor dose to 60 mg twice daily (not 90 mg) for long-term secondary prevention 3

High-Risk Features Favoring Extended Therapy

Patients with complex coronary disease may benefit from prolonged DAPT: 3

• Multivessel disease including left main involvement
• Prior myocardial infarction
• Chronic kidney disease
• History of stent thrombosis
• Complex PCI (multivessel stenting, >30 mm stent length, bifurcation lesions)

Early Discontinuation Scenarios

ACS Patients with High Bleeding Risk

Discontinuation after 6 months may be reasonable if: 1, 2

• Patient develops high bleeding risk (e.g., requires oral anticoagulation therapy)
• Patient is at high risk of severe bleeding complications (e.g., major intracranial surgery planned)
• Patient develops significant overt bleeding

SIHD Patients with High Bleeding Risk

Discontinuation after 3 months may be reasonable if: 1, 2

• Patient develops treatment indication requiring oral anticoagulation
• Patient faces high risk of severe bleeding complications
• Significant overt bleeding occurs

General Principle for Early Discontinuation

If the morbidity risk from bleeding clearly outweighs the anticipated ischemic benefit, earlier discontinuation is reasonable 1

Critical Management Points

Aspirin Dosing

• Use 81 mg daily (acceptable range 75-100 mg) when combined with ticagrelor 1, 2
• Higher aspirin doses increase bleeding without improving efficacy 1, 3
• Aspirin should be continued indefinitely after stopping ticagrelor 1, 3

If CABG is Required

• Stop ticagrelor at least 3 days before elective CABG 1, 3
• Resume ticagrelor as soon as possible after CABG to complete the 12-month course in ACS patients 1, 3
• Aspirin should be continued throughout the perioperative period 1

Common Pitfalls to Avoid

Do not stop ticagrelor before 12 months in ACS patients without compelling bleeding reasons - this dramatically increases thrombotic risk including stent thrombosis 1, 2, 3

Do not use ticagrelor 90 mg twice daily for therapy extending beyond 12 months - the approved dose for long-term secondary prevention is 60 mg twice daily 3

Do not discontinue therapy without discussing with the interventional cardiologist - premature cessation is a leading cause of stent thrombosis 2

Do not use aspirin doses >100 mg daily with ticagrelor - this increases bleeding without additional benefit 1, 3

Do not abruptly stop aspirin after discontinuing ticagrelor - aspirin monotherapy should continue for life 1, 3

Do not prescribe prasugrel instead of ticagrelor if the patient has prior stroke or TIA - prasugrel is contraindicated in these patients 1, 3