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Non–ST-Elevation Acute Coronary Syndromes

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21 Table 16. Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care (cont'd) Recommendations COR LOE Late hospital and posthospital oral antiplatelet therapy (cont'd) In patients receiving a stent (bare-metal stent or DES) during PCI for NSTE-ACS, P2Y 12 inhibitor therapy should be given for ≥12 months. Options include: • Clopidogrel: 75 mg daily or • Prasugrel: a 10 mg daily or • Ticagrelor: b 90 mg twice daily I B It is reasonable to use an ASA maintenance dose of 81 mg per day in preference to higher maintenance doses in patients with NSTE- ACS treated either invasively or with coronary stent implantation. IIa B It is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y 12 treatment in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strateg y. IIa B It is reasonable to choose prasugrel over clopidogrel for maintenance P2Y 12 treatment in patients with NSTE-ACS who undergo PCI who are not at high risk for bleeding complications. IIa B If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y 12 inhibitor therapy aer stent implantation, earlier discontinuation (e.g., <12 months) of P2Y 12 inhibitor therapy is reasonable. IIa C Continuation of DAPT beyond 12 months may be considered in patients undergoing stent implantation. IIb C Combined oral anticoagulant therapy and antiplatelet therapy in patients with NSTE-ACS e duration of triple antithrombotic therapy with a vitamin K antagonist, ASA, and a P2Y 12 receptor inhibitor in patients with NSTE-ACS should be minimized to the extent possible to limit the risk of bleeding. I C Proton pump inhibitors should be prescribed in patients with NSTE-ACS with a history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, ASA, and a P2Y 12 receptor inhibitor. I C Proton pump inhibitor use is reasonable in patients with NSTE- ACS without a known history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, ASA, and a P2Y 12 receptor inhibitor. IIa C Targeting oral anticoagulant therapy to a lower international normalized ratio (e.g., 2.0-2.5) may be reasonable in patients with NSTE-ACS managed with ASA and a P2Y 12 inhibitor. IIb C 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.

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