Treatment
ÎÎA loading dose of P2Y12 receptor inhibitor therapy is recommended for
UA/NSTEMI patients for whom PCI is planned.a One of the following
regimens should be used (see Table 4):
• Clopidogrel 600 mg should be given as early as possible before or at the time of
PCI (I-B), or
• Prasugrelb 60 mg should be given promptly and no later than 1 hour after PCI
once coronary anatomy is defined and a decision is made to proceed with PCI
(I-B), or
• Ticagrelorb 180 mg should be given as early as possible before or at the time of
PCI (I-B).
ÎÎThe duration and maintenance dose of P2Y12 receptor inhibitor therapy
should be as follows:
• In UA/NSTEMI patients undergoing PCI, either clopidogrel 75 mg daily, prasugrelb
10 mg daily, or ticagrelorb 90 mg twice daily should be given for at least 12 months.
(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)
ÎÎFor UA/NSTEMI patients in whom an initial conservative strategy is
selected and who have recurrent ischemic discomfort with ASA, a
P2Y12 receptor inhibitor (clopidogrel or ticagrelorb), and anticoagulant
therapy, it is reasonable to add a GP IIb/IIIa inhibitor before
diagnostic angiography. (IIa-C)
ÎÎFor UA/NSTEMI patients in whom an initial invasive strategy is
selected, it is reasonable to omit administration of an IV GP IIb/IIIa
inhibitor if bivalirudin is selected as the anticoagulant and at least 300
mg clopidogrel was administered at least 6 hours earlier than planned
catheterization or PCI. (IIa-B)
ÎÎFor UA/NSTEMI patients in whom an initial conservative (ie, noninvasive)
strategy is selected, it may be reasonable to add eptifibatide or tirofiban
to anticoagulant and oral antiplatelet therapy. (IIb-B)
ÎÎPrasugrelb 60 mg may be considered for administration promptly upon
presentation in patients with UA/NSTEMI for whom PCI is planned,
before definition of coronary anatomy, if both the risk for bleeding is
low and the need for CABG is considered unlikely. (IIb-C)
ÎÎThe use of upstream GP IIb/IIIa inhibitors may be considered in highrisk UA/NSTEMI patients already receiving ASA and a P2Y12 receptor
inhibitor (clopidogrel or ticagrelorb) who are selected for an invasive
strategy, such as those with elevated troponin levels, diabetes, or
significant ST-segment depression, and who are not otherwise at high
risk for bleeding. (IIb-B)
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