Figure 2. Flowchart for Class I and Class IIa
Recommendations for Initial Management of UA/NSTEMI
Diagnosis of UA/NSTEMI is likely or definite
ASA (I-A)a
Select Management Strategy
Initial Conservative Strategy
or Unknown
Invasive Strategyb
Initiate anticoagulant therapy
(I-A)
Acceptable options include:
• Enoxaparin or UFH (I-A)
• Bivalirudin (I-B)
• Fondaparinux (I-B)c
Initiate anticoagulant therapy (I-A)
Acceptable options include:
• Enoxaparin or UFH (I-A)
• Fondaparinux (I-B)
• Enoxaparin or fondaparinux
preferred over UFH (IIa-B)
Precatheterization:
Add second antiplatelet agent (I-A)d
•Clopidogrel or ticagrelor (I-B) or
•GP lIb/IIIa inhibitor (I-A)
(IV eptifibatide or tirofiban preferred)
Initiate clopidogrel or
ticagrelor (I-B)
Next step per triage decision at angiography
CABG:
Maintenance ASA (I-A)
Medical Therapy:
D/C GP IIb/IIIa inhibitors if begun and
give clopidogrel per conservative strategy
PCI:
• Clopidogrel (I-A) or ticagrelor (I-B) (if not begun precatheterization) or
• Prasugrel (I-B) or
• Selectively, a GP IIb/IIIa inhibitor (if not begun precatheterization) (I-A)
A loading dose followed by a daily maintenance dose of either clopidogrel (B), prasugrel (in
PCI-treated patients), or ticagrelor (C) should be administered to UA/NSTEMI patients who are
unable to take ASA because of hypersensitivity or major GI intolerance.
b
Timing of invasive strategy generally is assumed to be 4-48 hours. If immediate angiography is
selected, see STEMI guidelines.
c
If fondaparinux is used during PCI (I-B), it must be coadministered with another anticoagulant
with Factor IIa activity (ie, UFH).
d
Precatheterization triple antiplatelet therapy (ASA, clopidogrel or ticagrelor, glycoprotein
inhibitors) is a IIb-B recommendation for selected high-risk patients. Also, note that there are no
data for therapy with 2 concurrent P2Y12 receptor inhibitors, and this is not recommended in the
case of ASA allergy.
a
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