ACC GUIDELINES Bundle (free trial)

Treatment Table 4. Dosing for Commonly Used Antiplatelet and Anticoagulant Therapy to Support PCI in UA/NSTEMI (continued) During PCI Druga Patient Received Initial Medical Treatment (With a P2Y12 Receptor Inhibitor) Patient Did Not Receive Initial Medical Treatment (With a P2Y12 Receptor Inhibitor) P2Y12 receptor inhibitors (continued) Ticagrelord Patients who are already receiving clopidogrel should receive a loading dose of ticagrelor LD of 180 mg orally (I-B) MD of 90 mg orally twice daily (I-B) Parenteral anticoagulantse Bivalirudin For patients who have received UFH, wait 30 min, then give   0.75 mg/kg bolus, then   1.75 mg/kg per h infusion (I-B) 0.75 mg/kg bolus, 1.75 mg/kg per h infusion UFH IV GP IIb/IIIa planned: target ACT 200-250 s No IV GP IIb/IIIa planned: target ACT 250-300 s for HemoTec, 300-350 s for Hemochron (I-B) IV GP IIb/IIIa planned:   50-70 units/kg bolus to achieve an ACT of 200-250 s No IV GP IIb/IIIa planned: 70-100 units/kg bolus to achieve target ACT of 250-300 s   for HemoTec, 300-350 s for Hemochron (I-B) a This list is in alphabetical order and is not meant to indicate a particular therapy preference. This drug table does not make recommendations for combinations of listed drugs. It is only meant to indicate an approved or recommended dosage if a drug is chosen for a given situation. b ASA should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and be continued indefinitely in patients who tolerate it. After an initial loading dose (162-325 mg non-enteric formulation of ASA, orally or chewed), 81 mg of ASA per day is reasonable to use in preference to higher maintenance doses in patients with UA/NSTEMI, including those who underwent PCI. c The optimum LD of clopidogrel has not been established. Randomized trials establishing its efficacy and providing data on bleeding risks used an LD of 300 mg orally followed by a daily oral dose of 75 mg. Higher oral LDs such as 600 mg or >900 mg clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of inhibition of platelet aggregation, but the additive clinical efficacy and safety of higher oral LDs have not been rigorously established. For post-PCI patients receiving a DES, a daily MD should be given for at least 12 mo unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor. For post-PCI patients receiving a BMS, an MD should be given for up to 12 mo (unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor; then it should be given for a minimum of 2 wk). The necessity of giving an LD of clopidogrel before PCI is driven by the pharmacokinetics of clopidogrel, for which a period of several hours is required to achieve desired levels of platelet inhibition. 20

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