14
Treatment
Table 11. Myocardial Revascularization
Recommendations
COR LOE
PCI—General considerations
A strateg y of multivessel PCI, in contrast to culprit lesion−only
PCI, may be reasonable in patients undergoing coronary
revascularization as part of treatment for NSTE-ACS.
IIb B
PCI—Oral and intravenous antiplatelet agents
Patients already taking daily ASA before PCI should take
81-325 mg non–enteric-coated ASA before PCI.
I B
Patients not on ASA therapy should be given non−enteric-coated
ASA 325 mg as soon as possible before PCI.
I B
Aer PCI, ASA should be continued indefinitely at a dose of 81-
325 mg daily.
I B
A loading dose of a P2Y
12
receptor inhibitor should be given
before the procedure in patients undergoing PCI with stenting.
Options include:
I A
• Clopidogrel: 600 mg or
• Prasugrel:
a
60 mg or
• Ticagrelor:
b
180 mg
B
In patients with NSTE-ACS and high-risk features (e.g., elevated
troponin) who are not adequately pretreated with clopidogrel or
ticagrelor, it is useful to administer a GPI (abciximab, double-bolus
eptifibatide, or high-dose bolus tirofiban) at the time of PCI.
I A
a
Patients should receive a loading dose of prasugrel provided that they were not pretreated with
another P2Y
12
receptor inhibitor.
b
e recommended maintenance dose of ASA to be used with ticagrelor is 81 mg daily.
Table 10. Risk Stratification Before Discharge for Patients
With an Ischemia-Guided Strategy of NSTE-ACS
Recommendations
COR LOE
Noninvasive stress testing is recommended in low- and
intermediate-risk patients who have been free of ischemia at rest or
with low-level activity for a minimum of 12-24 h.
I B
Treadmill exercise testing is useful in patients able to exercise in
whom the ECG is free of resting ST changes that may interfere
with interpretation.
I C
Stress testing with an imaging modality should be used in patients
who are able to exercise but have ST changes on resting ECG
that may interfere with interpretation. In patients undergoing a
low-level exercise test, an imaging modality can add prognostic
information.
I B
Pharmacological stress testing with imaging is recommended when
physical limitations preclude adequate exercise stress.
I C
A noninvasive imaging test is recommended to evaluate LV
function in patients with definite ACS.
I C
