Treatment
Additional Management Considerations for Antiplatelet
and Anticoagulant Therapy
ÎÎFor UA/NSTEMI patients in whom an initial conservative strategy is
selected and no subsequent features appear that would necessitate
diagnostic angiography (recurrent symptoms/ischemia, HF, or serious
arrhythmias), a stress test should be performed. (I-B)
• If, after stress testing, the patient is classified as not at low risk, diagnostic
angiography should be performed. (I-A)
• If, after stress testing, the patient is classified as being at low risk, the
instructions noted below should be followed in preparation for discharge:
▶▶ Continue ASA indefinitely. (I-A)
▶▶ Continue clopidogrel or ticagrelor (see Table 3) for up to 12 months. (I-B)
▶▶ Discontinue IV GP IIb/IIIa inhibitor if started previously. (I-A)
▶▶ Continue UFH for 48 hours (I-A) or administer enoxaparin (I-A) or
fondaparinux (I-B) for the duration of hospitalization, up to 8 days, and
then discontinue anticoagulant therapy.
ÎÎFor UA/NSTEMI patients in whom CABG is selected as a
postangiography management strategy, the instructions noted below
should be followed.
• Continue ASA. (I-A)
• Discontinue IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 hours before
CABG. (I-B)
• Anticoagulant therapy should be managed as follows:
▶▶ Continue UFH. (I-B)
▶▶ Discontinue enoxaparin 12-24 hours before CABG and dose with UFH per
institutional practice. (I-B)
▶▶ Discontinue fondaparinux 24 hours before CABG and dose with UFH per
institutional practice. (I-B)
▶▶ Discontinue bivalirudin 3 hours before CABG and dose with UFH per
institutional practice. (I-B)
ÎÎIn patients taking a P2Y12 receptor inhibitor in whom CABG is planned
and can be delayed, it is recommended that the drug be discontinued
to allow for dissipation of the antiplatelet effect (I-B). The period
of withdrawal should be at least 5 days in patients receiving
clopidogrel (I-B) or ticagrelor (I-C) (see Table 3) and at least 7 days
in patients receiving prasugrel (I-C) (see Table 3) unless the need for
revascularization and/or the net benefit of the P2Y12 receptor inhibitor
therapy outweighs the potential risks of excess bleeding. (I-C)
ÎÎFor UA/NSTEMI patients in whom PCI has been selected as a
postangiography management strategy, the instructions noted below
should be followed:
• Continue ASA. (I-A)
• Administer a loading dose of a P2Y12 receptor inhibitor if not started before
diagnostic angiography. (I-A)
• Discontinue anticoagulant therapy after PCI for uncomplicated cases. (I-B)
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