Treatment
Long-Term Medical Therapy and Secondary Prevention
(For updated guidelines on secondary prevention beyond the acute phase of UA/NSTEMI, please
refer to the 2011 Secondary Prevention Guideline [JACC, http://content.onlinejacc.org/article.
aspx?articleid=1147807; Circulation, http://circ.ahajournals.org/content/124/22/2458.full] or
the 2012 Stable Ischemic Heart Disease Guideline [JACC, http://content.onlinejacc.org/article.
aspx?articleid=1147807; Circulation, http://circ.ahajournals.org/content/124/22/2458.full].)
Antiplatelet Therapy
ÎÎFor UA/NSTEMI patients treated medically without stenting, ASA a
should be prescribed indefinitely (I-A); clopidogrel (75 mg daily)
or ticagrelorb (90 mg twice daily) should be prescribed for up to 12
months. (I-B)
ÎÎFor UA/NSTEMI patients treated with a stent (BMS or DES), ASAa
should be continued indefinitely. (I-A) The duration and maintenance
dose of P2Y12 receptor inhibitor therapy should be as follows:
• Clopidogrel 75 mg daily, prasugrelb 10 mg, or ticagrelorb 90 mg twice daily
should be given for at least 12 months in patients receiving DES and up to 12
months for patients receiving BMS. (I-B)
• If the risk of morbidity because of bleeding outweighs the anticipated benefits
afforded by P2Y12 receptor inhibitor therapy, earlier discontinuation should be
considered. (I-C)
ÎÎClopidogrel 75 mg daily (I-B), prasugrelb 10 mg daily (in PCI-treated
patients (I-C), or ticagrelorb 90 mg twice daily (I-C) should be given
to patients recovering from UA/NSTEMI when ASA is contraindicated
or not tolerated because of hypersensitivity or GI intolerance (despite
use of gastroprotective agents such as PPIs).
ÎÎAfter PCI, it is reasonable to use 81 mg/d ASA in preference to higher
maintenance doses. (IIa-B)
ÎÎFor UA/NSTEMI patients who have an indication for anticoagulation,
the addition of warfarin c may be reasonable to maintain an INR of 2.03.0.d (IIb-B)
ÎÎContinuation of a P2Y12 receptor inhibitor beyond 12 months may be
considered in patients after DES placement. (IIb-C)
ÎÎDipyridamole is NOT recommended as an antiplatelet agent in postUA/NSTEMI patients because it has not been shown to be effective.
(III: No Benefit-B)
a
For ASA-allergic patients, use either clopidogrel or ticagrelor alone (indefinitely) or try ASA
desensitization. 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.
b
See Table 3.
c
Continue ASA indefinitely and warfarin longer term as indicated for specific conditions such as
atrial fibrillation; LV thrombus; or cerebral, venous, or pulmonary emboli.
d
An INR of 2.0-2.5 is preferable while given with ASA and a P2Y12 receptor inhibitor, especially in
older patients and those with other risk factors for bleeding. For UA/NSTEMI patients who have
mechanical heart valves, the INR should be at least 2.5 (based on type of prosthesis).
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