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Treatment 10 Table 8. Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS Recommendations COR LOE Initial oral and intravenous antiplatelet therapy in patients with definite or likely NSTE-ACS treated with an initial invasive or ischemia-guided strategy Non-enteric-coated, chewable ASA (162-325 mg ) should be given to all patients with NSTE-ACS without contraindications as soon as possible aer presentation, and a maintenance dose of ASA (81-325 mg daily) should be continued indefinitely. I A In patients with NSTE-ACS who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance, a loading dose of clopidogrel followed by a daily maintenance dose should be administered. I B A P2Y 12 inhibitor (either clopidogrel or ticagrelor) in addition to ASA should be administered for ≤12 months to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strateg y. Options include: • Clopidogrel: 300-mg or 600-mg loading dose, then 75 mg daily • Ticagrelor: a 180-mg loading dose, then 90 mg twice daily I B It is reasonable to use ticagrelor in preference to clopidogrel for P2Y 12 treatment in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strateg y. IIa B In patients with NSTE-ACS treated with an early invasive strategy and DAPT with intermediate/high-risk features (e.g., positive troponin), a glycoprotein (GP) IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. Preferred options are eptifibatide or tirofiban. IIb B Initial parenteral anticoagulant therapy in patients with definite NSTE-ACS In patients with NSTE-ACS, anticoagulation, in addition to antiplatelet therapy, is recommended for all patients irrespective of initial treatment strategy. Treatment options include: • Enoxaparin: 1 mg/kg SC every 12 h (reduce dose to 1 mg/kg SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial intravenous loading dose of 30 mg has been used in selected patients. I A • Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg/h (only in patients managed with an early invasive strategy), continued until diagnostic angiography or PCI, with only provisional use of GPI, provided the patient is also treated with DAPT. B • Fondaparinux: 2.5 mg SC daily, continued for the duration of hospitalization or until PCI is performed. B • If PCI is performed while the patient is on fondaparinux, an additional anticoagulant with anti-IIa activity (either UFH or bivalirudin) should be administered because of the risk of catheter thrombosis. B • UFH IV: initial loading dose of 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg/hr (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 h or until PCI is performed. B a e recommended maintenance dose of ASA to be used with ticagrelor is 81 mg daily.