An Illustrative Case of the TWILIGHT COMPLEX Study

A 66-year-old male patient presented to your office for evaluation of chest discomfort. He described his symptoms, which began approximately 3 weeks ago, as a pressure associated with shortness of breath that occurred with moderate exertion such as walking up hills or a flight of steps. Symptoms were relieved spontaneously within 5 minutes with rest. However, in the few days prior to his visit with you, he noticed symptoms were occurring with less exertion and were more intense and lasted longer, prompting him to use his old sublingual nitroglycerin twice in the last 2 days. He did not report rest angina.

His medical history was notable for hypertension, prior myocardial infarction with previous stenting to the right coronary artery, diabetes, and increased cholesterol. Current medications included aspirin 81 mg daily, metoprolol succinate 25 mg daily, amlodipine 5 mg daily, metformin 500 mg twice daily, and pravastatin 40 mg daily. His physical exam demonstrated a blood pressure of 148/75 mmHg, heart rate of 74 bpm, and respiratory rate of 16. The remainder of the physical exam was normal. Admission laboratory results were notable for a creatinine of 1.6 mg/dl with a creatinine clearance of 46 ml/min, hemoglobin of 11.5 g/dl (normal range 13.2-17), white blood cell count of 11 10e9 (upper range of normal 9.7 10e9 ), high-density lipoprotein of 45 mg/dL, low-density lipoprotein of 70 mg/dL, and hemoglobin A1c of 7.1%. His electrocardiogram showed mild lateral ST depression with left ventricular hypertrophy changes. You subsequently ordered stress myocardial perfusion imaging, which was performed the next day. He exercised for 3 minutes on a Bruce protocol before developing substernal chest discomfort and 2 mm of ST depression. Symptoms resolve in recovery within 5 minutes. Imaging demonstrates a large, moderate- to high-grade, mostly reversible anterior defect accounting for approximately 20% of the left ventricle. Ejection fraction was 55% at rest, decreasing to 45% post stress. Given the frequency of angina, the fact that it occurred at such a low workload, and that he was currently on 2 antianginals, the decision was made to proceed with coronary angiography, which was performed the next day. This demonstrated an 80% proximal left anterior descending artery stenosis involving the origin of the diagonal, 40% mid left circumflex lesion, and a 50% proximal right coronary artery lesion proximal to the prior patent stent. Successful stenting of bifurcating left anterior descending/D1 lesion was performed using the double kiss crush technique. Two second-generation everolimus-eluting stents were employed with total stent length of 40 mm. Pravastatin was changed to atorvastatin 80 mg, and he was subsequently discharged with aspirin and ticagrelor in addition to his other medications.

He follows up with you at 1 and 3 months and has not had recurrent chest pain. However, he notes that when he cuts himself shaving, it often takes a half an hour to stop bleeding.

Based on the TWILIGHT COMPLEX (Ticagrelor With Aspirin or Alone in High-Risk Patients After Complex Percutaneous Coronary Intervention) study, which of the following would be appropriate?

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