Ticagrelor and Aspirin Loading Doses in Posterior Circulation Stroke

Loading Dose Recommendations

The American College of Cardiology recommends a loading dose of 180 mg of ticagrelor and 162-325 mg of aspirin for patients with posterior circulation stroke, followed by maintenance doses of 90 mg twice daily for ticagrelor and 81 mg daily for aspirin 1, 2
The American Heart Association suggests that ticagrelor has a rapid onset of action, achieving significant platelet inhibition within 30 minutes of administration, with a peak inhibitory effect seen approximately 2 hours after the loading dose 3, 4
For patients with impaired swallowing, the International Journal of Stroke recommends rectal aspirin 325 mg as a reasonable alternative 5

The American College of Cardiology recommends 90 mg twice daily of ticagrelor following the loading dose, with the preferred maintenance dose of aspirin being 81 mg daily when used with ticagrelor 1, 2, 6
The Circulation journal notes that twice-daily dosing of ticagrelor may affect patient compliance 7, 8

The International Journal of Stroke recommends dual antiplatelet therapy with ticagrelor and aspirin for 30 days for minor ischemic stroke or high-risk TIA 5
The American College of Cardiology recommends that dual antiplatelet therapy should continue for at least 12 months for patients receiving drug-eluting stents 2

The Circulation journal advises that ticagrelor should be avoided in patients with prior history of intracranial hemorrhage, and caution is advised when considering ticagrelor in patients with prior stroke or TIA due to possible increased risk of intracranial bleeding 7, 8
The Circulation journal recommends discontinuing ticagrelor at least 5 days before planned surgery 6

The International Journal of Stroke suggests always ruling out intracranial hemorrhage on neuroimaging before initiating antiplatelet therapy, and initiating therapy as early as possible, ideally within 24 hours of symptom onset for maximum benefit 5
The Circulation journal notes that for patients already receiving clopidogrel, a loading dose of ticagrelor should still be administered when switching to ticagrelor, and ticagrelor does not require hepatic conversion to an active metabolite, providing more consistent platelet inhibition compared to clopidogrel 3, 4, 7, 8