Ticagrelor-Induced Junctional Bradycardia Following Primary Percutaneous Coronary Intervention: A Clinically Significant and Reversible Adverse Effect

Abstract

Background: Ticagrelor, a potent and reversible P2Y12 receptor antagonist, is a cornerstone of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS). While generally well tolerated, ticagrelor has been associated with conduction abnormalities, often considered transient and clinically insignificant. However, emerging evidence suggests that clinically meaningful bradyarrhythmias may occur, particularly in high-risk populations.

Case Presentation: We report the case of a 75-year-old hypertensive male presenting with acute anterior ST-elevation myocardial infarction (STEMI), who underwent successful primary percutaneous coronary intervention (PCI) to the left anterior descending artery. Standard post-PCI therapy, including ticagrelor, was initiated. Within 30 hours, the patient developed syncope, hypotension, and electrocardiographically confirmed junctional bradycardia.

Management and Results: Initial management included withholding beta-blocker therapy; however, the bradyarrhythmia persisted beyond expected pharmacological effects. Ticagrelor was subsequently discontinued and replaced with clopidogrel. Following this intervention, normal sinus rhythm was restored within 36 hours, and the patient remained hemodynamically stable. No recurrence of bradyarrhythmia was observed during three months of follow-up.

Conclusion: This case highlights ticagrelor as a potential reversible cause of clinically significant junctional bradycardia in elderly patients following PCI. Recognition of this adverse effect is crucial to avoid unnecessary invasive interventions and to enable timely modification of antiplatelet therapy. Clinicians should maintain vigilance for bradyarrhythmias associated with ticagrelor, particularly in susceptible individuals.