Table 3

Current dual antiplatelet therapy protocol for Pipeline Embolization Device procedures

Initiation of DAT10 days pre-procedure
Target P2Y12 receptor inhibitionPRU 60–240
Target aspirin inhibition≥50%
Initial aspirin dose81 mg daily
Initial clopidogrel dose75 mg daily
Pre-procedure aspirin inhibition testing*Day before procedure
Pre-procedure P2Y12 receptor inhibition testingDay before procedure
Hyporesponders to aspirin (<50% inhibition)Aspirin, 325 mg daily
Hyporesponders to clopidogrel (PRU>240)Clopidogrel, 150 mg daily†
Hyperresponders to clopidogrel (PRU<60)Clopidogrel, 75 mg every other day, every third day, every Monday and Friday, every fifth day or once a week, as needed to reach target PRU range
Reschedule procedure‡PRU <60 or >240
Post-procedure P2Y12 receptor inhibition testing10 and 30 days after any clopidogrel dose adjustment, after changes to medications that may affect clopidogrel metabolism, or at any time if symptomatic with abnormal bruising/bleeding or focal neurological deficits
  • *Aspirin inhibition testing performed with a standard collagen platelet aggregation assay.

  • Hyporesponders to 150 mg daily clopidogrel dose (PRU>240) are started on ticagrelor (180 mg×1, then 90 mg twice a day) the day before the procedure without further P2Y12 receptor inhibition testing.

  • ‡Expected rescheduling rate of 35.7%.

  • DAT, dual antiplatelet therapy; PRU, P2Y12 reaction units.