Ticagrelor is a potent, oral P2Y12 inhibitor used as a part of dual antiplatelet
therapy (
DAPT) in
acute coronary syndromes (ACS). New evidence has emerged for its use in ACS, which may be crucial for the Indian context. This brought together nearly 150 experts in ACS management across the country who reviewed the current evidence and discussed the same through a series of 10 meetings on an online platform. With all experts' agreement, the key expert opinions for the P2Y12 inhibitors use in ACS management were finalized. These include the following. In ACS patients aged <75 years, with diabetes, a history of
stroke/
transient ischemic attack, and
chronic kidney disease,
ticagrelor may be preferred over other P2Y12 inhibitors. It may also be preferred in the elderly above 75 years with
clopidogrel is a suitable alternative in patients at high-risk of
bleeding. Rates of
stent thrombosis are lower with
ticagrelor than
clopidogrel. In patients managed with fibrinolysis, use
ticagrelor after 48 hours if
streptokinase was the
fibrinolytic agent or it can be used after 12 to 24 hours if
fibrin-specific fibrinolytic was used. Rates of major
bleeding in patients treated with fibrinolysis are similar to
clopidogrel. Prehospital administration may be preferred over in-hospital administration with expected
bleeding rates similar to
clopidogrel. Switching among P2Y12 inhibitors should be done with due consideration of their pharmacodynamics. At present,
DAPT should be continued for 12 months with discontinuation after three to six months in patients with high
bleeding risk. The use of low dose
ticagrelor may be considered in cases with high-
bleeding risk.
DAPT or
ticagrelor continuation beyond one year should be individualized considering ischemic and
bleeding risks.
Dyspnea is a common, mild, and transient and does not necessitate
ticagrelor discontinuation. Severe
dyspnea should be investigated thoroughly. In conclusion,
ticagrelor (180 mg, 90 mg, and 60 mg doses), a potent antiplatelet is expected to reshape the antiplatelet use in the management of ACS.