• Should not be added if on oral anticoagulants

  • Generally Not recommended risk \<20%

  • Can be considered for high-risk primary prevention: taking into account harms and benefits

  • Strongly recommended people with established cardiovascular disease

    • reduces risk of cardiovascular event by about 25%

after angina or MI

  • low dose aspirin

risk >20%

  • commence aspirin

contraindications:

  • Aspirin allergies/intolerance

  • active peptic ulceration

  • uncontrolled BP and other major bleeding risks)

risks

  • intracranial haemorrhage = 2/1000 / year

  • extracranial haemorrhage 1-2/1000

    • most non-fatal

  • upper GI bleed/perforation

    • 2x increase

Ticagrlor (Brilinta)

  • reversibly inhibits platelet adenosine diphosphate p2y12 receptors

    • rapid inhibition of platelet activation and aggregation

    • clopidogrel = prodrug

      • CYP2c19

      • 30-40% people of Maori, PI and aisan decent

        • reduced CYP2c19

        • compared to 15% Eruopeans

  • co-administered with aspirin

    • dual anti-platelet

  • indicated prevention of atherothromboci events in adult patients with ACS

    • N-STEACS/STEACS

  • Special authority

    • Patient has recently been diagnosed with STEACS/STEACS

      • days/weeks compared to months

    • Fibrinolytic therapy not been given in the last 24 hours and is not planned

  • Evidence

    • PLATO

      • ticagrelor + aspirin > clopidogrel + aspirin

        • lower risk of ischaemic events and death

        • absolute risk reduction 16%

        • RR 16%

        • NNT 54

  • load with 180mg

  • 90mg bd with or without food

  • Black box warning

    • should not be used concurrrently with doses of aspirin >100mg

  • contraindications

    • active bleeding

    • history of intracranial haemorrhage

    • no data on safety in those who have had fibrinolytic thearpy

  • cautions

    • increase risk of bleeding

    • nsaids

    • ?brady cardia

      • excluded from PLATO

      • used with caution unless PPM fitted

  • Interactions

    • CYP3A4

    • weak inhibitor

  • Adverse effects

    • Bleeding

    • Dyspnoea

      • increase risk of dyspnoea compared to clopidogrel

      • ?mechanism

    • elevations in Cr and urate