MK is a 59-year-old male who presented with a chief complaint of epistaxis. He has a past-surgical history of carotid artery endarterectomy and percutaneous coronary stent placement. He had a total occlusion of the RCA and a 70% occlusion of the LAD that approached 90% at the ostium. Two drug-eluting stents were inserted into the LCX in December 2020, and a third was placed in the proximal LAD this past February. A third PCI/DES is planned imminently.
MK had been on dual anti-platelet therapy (aspirin + ticagrelor) since the beginning of March. Over the past week or so, he presented to the Garden City ER after he began experiencing nose bleeds. No blood work was performed, and the patient was instructed to put gauze in his nares. In his follow-up visit to the clinic on April 20, MK brought his medications. ROS was positive for nosebleeds but negative for hemoptysis/hematochezia/hematuria. He had recently acquired a bottle of clopidogrel although this med was not found in his chart. Between the aspirin, clopidogrel, and ticagrelor, the patient was confused as to which pills to take and when. We instructed him to discontinue the ticagrelor. Instead, we clarified that he is to take one aspirin and one clopidogrel per day. His next visit with his cardiologist is on May 27.
What is this patient asking us to “get smart” about? On the most immediate level, he wants us to help him lower his risk of minor bleeding (i.e. from the nose). We take that one step further by also considering the possibility of major bleeding. A goal is a pharmaceutical alternative that ameliorates epistaxis while first and foremost maintaining stent integrity. We must also consider that the patient has many co-morbidities, is a poor historian, and his medication compliance is uncertain.
Both ticagrelor and clopidogrel are PGY12 inhibitors that prevent platelet aggregation. This class is indicated for finite periods of time in high-risk patients after the placement of a coronary stent. Anti-platelet agents reduce the risk of thrombosis and therefore Major Acute Coronary Events (MACE).
I reviewed an original investigation from JAMA Internal Medicine: Association of Ticagrelor vs Clopidogrel with Major Adverse Coronary Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention (2020). The study compared the risk of MACE in patients prescribed one of the two drugs after PCI. All subjects took aspirin concurrently. It concluded that outpatient use of ticagrelor is not superior to clopidogrel in lowering the risk of MACE. The adjusted analysis demonstrated that ticagrelor does increase the risk of major bleeds compared to clopidogrel. There was no mention of nosebleeds.
In the study of over 11,000 subjects, clopidogrel was the more frequently prescribed anti-platelet after PCI (63.6%). Clopidogrel users were more likely to have serious co-morbidities. Ticagrelor users were younger and tended toward fewer cardiac risk factors and comorbidities. Patients taking ticagrelor were reported to have higher adherence. However, 14% of ticagrelor users switched their anti-platelet during the course of the study; this only occurred in 2.3% of the clopidogrel arm. Ticagrelor was associated with a higher incidence of major bleeding, and its users were more likely to report to the ED for dyspnea.
MK would be optimally served with an anti-platelet plus aspirin. Clopidogrel and ticagrelor are equivalent when it comes to preventing post-PCI MACE. The best choice for him is a matter of adherence, which could be encouraged with a written-out medication schedule and blister packs. The patient mentioned how he did not like taking ticagrelor twice a day. The clopidogrel dose calls for one a day. It has the added benefit of lowering his risk for major bleeding, and to that end minor bleeding.
Benjamin Samuel Young 