ACC GUIDELINES Bundle (free trial)

Comments – All Patients to Receive ASAb •  The recommended maintenance dose of ASA to be used with ticagrelor is 81 mg daily. •  Ticagrelor's benefits were observed irrespective of prior therapy with clopidogrel (47% of patients in PLATO received clopidogrel at the time of randomization). •  Period of withdrawal before surgery should be at least 5 d. •  Issues of patient compliance may be especially important with twice-daily dosing regimen. •  Ticagrelor increases the risk of fatal ICH compared with clopidogrel and should be avoided in those with a prior history of ICH. Until further data become available, it seems prudent to weigh the possible increased risk of intracranial bleeding when considering the addition of ticagrelor to ASA in patients with prior stroke or TIA. •  Bivalirudin may be used to support PCI and UA/NSTEMI with or without previously administered UFH with the addition of 600 mg clopidogrel. •  In UA/NSTEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin anticoagulation is reasonable. Patients who have a reduced-function CYP2C19 allele have significantly lower levels of the active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of MACE, including stent thrombosis. In UA/NSTEMI patients taking clopidogrel for whom CABG is planned and can be delayed, it is reasonable to discontinue the clopidogrel to allow for dissipation of the antiplatelet effect unless the urgency for revascularization and/or the net benefit of clopidogrel outweigh the potential risks of excess bleeding. The period of withdrawal should be at least 5 d in patients receiving clopidogrel. d See Table 3. e Enoxaparin and fondaparinux can be used as alternative anticoagulant drugs during PCI. When enoxaparin is initiated during PCI for UA/NSTEMI, it should be administered as a 0.5- to   0.75-mg/kg IV bolus. In UA/NSTEMI patients who were treated with SC enoxaparin before PCI (and who achieved steady-state levels), additional dosing of enoxaparin depends on the timing from the last SC dose administered: (a) if the last SC dose was administered <8 h, no additional therapy with enoxaparin is recommended; (b) if the last SC dose was administered >8 h, additional therapy with 0.3 mg/kg IV bolus is recommended. Fondaparinux can be initiated as soon as possible after presentation with UA/NSTEMI as a 2.5-mg once-daily SC dose. During PCI, a 50- to 60-U/kg IV bolus of UFH is recommended to be added to fondaparinux by the OASIS 5 investigators (however, this regimen has not been rigorously tested in prospective randomized trials). Fondaparinux should be avoided for creatinine clearance<30 mL/min. Modified from Jneid H, et al. J Am Coll Cardiol. 2012;60(7):645-681. 21

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