Antiplatelet Therapy
ÎÎUA/NSTEMI patients who tolerate it should receive ASA as soon as
possible after hospital presentation and continue it indefinitely. (I-A)
ÎÎUA/NSTEMI patients who are unable to take ASA because of
hypersensitivity or major gastrointestinal (GI) intolerance should
receive a loading dose of clopidogrel (I-B), prasugrelb (in PCI-treated
patients) (I-C), or ticagrelorb (I-C) followed by a daily maintenance
dose.
ÎÎPatients with definite UA/NSTEMI at medium or high risk and in whom
an initial invasive strategy is selected (Table 4) should receive dual
antiplatelet therapy on presentation. (I-A)
• ASA should be initiated on presentation. (I-A)
• The choice of a second antiplatelet therapy to be added to ASA on presentation
includes one of the following:
Note: There are no data for therapy with 2 concurrent P2Y12 receptor
inhibitors, and this is not recommended in the case of ASA allergy.
• Before PCI:
▶▶ Clopidogrel (I-B) or
▶▶ Ticagrelorb (I-B) or
▶▶ An IV glycoprotein (GP) IIb/IIIa inhibitor (I-A). IV eptifibatide and
tirofiban are the preferred GP IIb/IIIa inhibitors. (I-B)
• At the time of PCI:
▶▶ Clopidogrel if not started before PCI (I-A) or
▶▶ Prasugrelb (I-B) or
▶▶ Ticagrelora,b (I-B) or
▶▶ An IV GP IIb/IIIa inhibitor (I-A).
ÎÎFor UA/NSTEMI patients in whom an initial conservative (ie,
noninvasive) strategy is selected, clopidogrel or ticagrelorb (loading
dose followed by daily maintenance dose) should be added to ASA
and anticoagulant therapy as soon as possible after admission and
administered for up to 12 months. (I-B)
ÎÎFor UA/NSTEMI patients in whom an initial conservative strategy
is selected, if recurrent symptoms/ischemia, HF, or serious
arrhythmias subsequently appear, then diagnostic angiography should
be performed. (I-A) Either an IV GP IIb/IIIa inhibitor (eptifibatide
or tirofiban [I-A]), clopidogrel (loading dose followed by daily
maintenance dose [I-B]), or ticagrelorb (loading dose followed by daily
maintenance dose [I-B]) should be added to ASA and anticoagulant
therapy before diagnostic angiography (upstream). (I-C)
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