Coronary Artery Disease

Key Points ÎAntithrombotic therapy is a mainstay in the management of patients with either acute or chronic coronary artery disease. ÎEarly treatment decisions for patients with acute myocardial ischemia have little influence on secondary prevention treatment strategy. Diagnosis and Assessment I. Acute Coronary Syndrome ÎFor ACS with and without STE, the ACCP recommends aspirin initially at a dose of 75-162 mg and then indefinitely at a dose of 75-100 mg/d (1A). ÎFor STE ACS, with or without fibrinolytic therapy, the ACCP recommends clopidogrel† 75 mg starting dose for those 75 years of age, and continued at a daily dose of 75 mg for 2-4 weeks (1A). The ACCP suggests continuing clopidogrel† up to 12 months following hospital discharge (2B). ÎFor NSTE ACS, the ACCP recommends combination therapy with aspirin (75-100 mg/d) and clopidogrel† (75 mg/d) for 12 months (1A). ÎFor patients in whom aspirin is contraindicated or not tolerated, the ACCP recommends clopidogrel† monotherapy (75 mg/d) (1A). ÎFor symptomatic CAD, the ACCP suggests aspirin (75-100 mg/d) in combination with clopidogrel† (75 mg/d) (2B). Values and preferences: This recommendation places a high value on the probable small reduction in arterial vascular risk consequent on adding clopidogrel† value on avoiding the additional bleeding and high cost associated with clopidogrel† ÎFor most patients (all except the high-risk group described below*) in most health-care settings, following ACS, the ACCP recommends aspirin alone (75-100 mg daily) over oral vitamin K antagonists (VKAs) alone or in combination with aspirin (1B). *For high-risk patients with MI, including those with a large anterior MI, those with significant heart failure, those with intracardiac thrombus visible on transthoracic echocardiography, those with atrial fibrillation and those with a history of a thromboembolic event, the ACCP suggests the combined use of moderate-intensity (INR, 2.0 to 3.0) oral VKA plus low-dose aspirin (< 100 mg/d) for ≥ 3 months after the MI (2A). Values and preferences: This recommendation places a relatively low value on prevention of thromboembolism, and a relatively high value on avoiding the inconvenience, expense, and bleeding risk associated with VKA therapy. ÎFor most patients after MI, in health care settings in which meticulous international normalized ratio (INR) monitoring and highly skilled VKA dose titration are expected and widely accessible, the ACCP suggests long-term (up to 4 years) high-intensity oral VKA (target INR, 3.5; range, 3.0 to 4.0) without concomitant aspirin or moderate-intensity oral VKA (target INR, 2.5; range 2.0 to 3.0) with aspirin (< 100 mg/d) over aspirin alone (both 2B). to aspirin and a low . as a 300 mg oral loading dose for patients < 75 years of age and for

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