Current dual antiplatelet therapy protocol for Pipeline Embolization Device procedures
| Initiation of DAT | 10 days pre-procedure |
| Target P2Y12 receptor inhibition | PRU 60–240 |
| Target aspirin inhibition | ≥50% |
| Initial aspirin dose | 81 mg daily |
| Initial clopidogrel dose | 75 mg daily |
| Pre-procedure aspirin inhibition testing* | Day before procedure |
| Pre-procedure P2Y12 receptor inhibition testing | Day 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 testing | 10 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.