Activity 2: Antiplatelet Therapy in ACS: What's Best Practice?

Recommendation #1: Aspirin should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients not known to be intolerant. (IA)
Source: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1-e157.
Website: http://content.onlinejacc.org/cgi/content/full/50/7/e1
Strength of Evidence: See table at the end of the document.

Recommendation #2: For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected, clopidogrel (loading dose followed by daily maintenance dose) should be added to aspirin and anticoagulant therapy as soon as possible after admission and administered for at least 1 month (IA) and ideally up to 1 year. (1C)
Source: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1-e157.
Website: http://content.onlinejacc.org/cgi/content/full/50/7/e1
Strength of Evidence: See table at the end of the document.

Recommendation #3: Clopidogrel, 75 mg per day orally, should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. (IA) Treatment with clopidogrel should continue for at least 14 days.(IB)
Source: 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. Circulation 2008:117:296-329.
Website: http://circ.ahajournals.org/cgi/content/full/117/2/296
Strength of Evidence: See table at the end of the document.

Recommendation #4: Patients already taking daily long-term aspirin therapy should take 75 mg to 325 mg of aspirin before PCI is performed. (IA)
Source: 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. Circulation 2008;117:261-295.
Website: http://circ.ahajournals.org/cgi/content/short/117/2/261
Strength of Evidence: See table at the end of the document.

Recommendation #5: Patients not already taking daily long-term aspirin therapy should be given 300 mg to 325 mg of aspirin at least 2 hours, and preferably 24 hours, before PCI is performed. (IC)
Source: 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. Circulation 2008;117:261-295.
Website: http://circ.ahajournals.org/cgi/content/short/117/2/261
Strength of Evidence: See table at the end of the document.

Recommendation #6: Patients with definite or likely UA/NSTEMI selected for an invasive approach should receive dual antiplatelet therapy. (IA) Aspirin should be initiated on presentation. (IA) Clopidogrel (before or at the time of PCI) (IA) or prasugrel (at the time of PCI) (IB) is recommended as a second antiplatelet agent.
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271#TBL3A192663
Strength of Evidence: See table at the end of the document.

Recommendation #7: A loading dose of thienopyridine is recommended for STEMI patients for whom PCI is planned. Regimen should be one of the following:

• Clopidogrel, 300 mg–600 mg, administered as early as possible before or when primary or nonprimary PCI is performed. (IC)
• Prasugrel, 60 mg, administered as soon as possible for primary PCI. (IB)
• For STEMI patients undergoing nonprimary PCI, the following regimens are recommended:
  • If patient received fibrinolytic therapy and clopidogrel, continue clopidogrel. (IC)
  • If patient received fibrinolytic therapy only, administer loading dose of clopidogrel (300 mg-600 mg). (IC)
  • If no fibrinolytic therapy administered, give either a loading dose of clopidogrel (300 mg-600 mg) or, once coronary anatomy is known and PCI planned, a loading dose of prasugrel (60 mg, promptly and no later than 1 hour after PCI). (IB)

Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271#TBL3A192663
Strength of Evidence: See table at the end of the document.

Recommendation #8: The duration of thienopyridine should be as follows: In patients receiving a stent (BMS or DES) during PCI for ACS, 75 mg daily of clopidogrel (IB) or 10 mg daily of prasugrel (IB) should be given for at least 12 months.
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271#TBL3A192663
Strength of Evidence: See table at the end of the document.

Recommendation #9: If the risk of morbidity because of bleeding outweighs the anticipated benefit afforded by thienopyridine therapy, earlier discontinuation should be considered. (IC)
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271#TBL3A192663
Strength of Evidence: See table at the end of the document.

Recommendation #10: Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients undergoing DES implantation. (IIIbC)
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271#TBL3A192663
Strength of Evidence: See table at the end of the document.

Recommendation #11: Care should be taken to establish effective communication between the post- UA/NSTEMI patient and health care team to enhance long-term adherence to prescribed therapies and recommended lifestyle changes. (IB)
Source: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1-e157.
Website: http://content.onlinejacc.org/cgi/content/full/50/7/e1
Strength of Evidence: See table at the end of the document.

Recommendation #12: Before implantation of a stent, the physician should discuss the need for dual antiplatelet therapy. For patients not expected to comply with 12 months of thienopyridine therapy, whether for economic or other reasons, strong consideration should be given to avoiding a DES.
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271
Strength of Evidence: See table at the end of the document.

Recommendation #13: A greater effort by health care professionals must be made before patient discharge to ensure patients are properly and thoroughly educated about the reasons they are prescribed thienopyridines and the significant risks associated with prematurely discontinuing such therapy. (Expert consensus)
Source: Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. Circulation 2007;115:813-818.
Website: http://circ.ahajournals.org/cgi/reprint/115/6/813
Strength of Evidence: See table at the end of the document.

Recommendation #14: In patients who are undergoing preparation for PCI and are likely to require invasive or surgical procedures for which dual antiplatelet therapy must be interrupted during the next 12 months, consideration should be given to implantation of a BMS or performance of balloon angioplasty with provisional stent implantation instead of the routine use of a DES. (IC)
Source: 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-2306.
Website: http://circ.ahajournals.org/cgi/content/full/120/22/2271
Strength of Evidence: See table at the end of the document.

Recommendation #15: Elective procedures for which there is significant risk of perioperative or postoperative bleeding should be deferred until patients have completed an appropriate course of thienopyridine therapy (12 months after DES implantation if they are not at high risk of bleeding and a minimum of 1 month for BMS implantation). (Expert consensus)
Source: Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. Circulation 2007;115:813-818.
Website: http://circ.ahajournals.org/cgi/reprint/115/6/813
Strength of Evidence: See table at the end of the document.

Recommendation #16: For patients treated with DES who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued if at all possible and the thienopyridine restarted as soon as possible after the procedure because of concerns about late stent thrombosis. (Expert consensus)
Source: Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. Circulation 2007;115:813-818.
Website: http://circ.ahajournals.org/cgi/reprint/115/6/813
Strength of Evidence: See table at the end of the document.

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Coronary Artery Disease and the Use of Stents Handout. Am Fam Physician 2009;80(11):1252-53.  http://www.aafp.org/afp/2009/1201/p1252.html?printable=afp:

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Presentation Slides for Antiplatelet Therapy in ACS: What’s Best Practice?

Abbreviations and Acronyms

Articles:

• Dehmer GJ, Smith KJ. Drug-eluting Coronary Artery Stents. Am Fam Physician 2009;80(11):1245-51.
• CURE/PCI CURE: The CURE Trial Investigators. Effects of Clopidogrel in Addition to Aspirin in Patients with Acute Coronary Syndromes without ST-Segment Elevation. N Engl J Med 2001; 345:494-502 and Mehta SR, Yusuf S, Peters RJG, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001;358(9281):527-33.
• CURRENT OASIS 7: ESC 2009. Mehta SR, Tanguay JF, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): A randomised factorial trial. Lancet 2010;376(9748):1233-43.
• CAPRIE: CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996;348(9038):1329-39.
• Sarkees M, Bavry A. Acute coronary syndrome (unstable angina and non-ST-elevation myocardial infarction). Am Fam Physician 2009;80(4):383-4.
• Montalescot G, Wiviott SD, Braunwald E, et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 2009;373(9665):723-31.
• PLATO: Cannon CP, Harrington RA, James S, et al. Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes. N Engl J Med 2009;361:1045-57 and Wallentin L, Becker RC, Budaj A, et al. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet 2010;375(9711):283-93.

Guidelines:

1. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. Circulation 2008:117:296-329.
   http://circ.ahajournals.org/cgi/content/full/117/2/296
2. 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention. Circulation 2008;117:261-295.
   http://circ.ahajournals.org/cgi/content/short/117/2/261
3. 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients With STEMI (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-306.
   http://circ.ahajournals.org/cgi/content/full/120/22/2271
4. 2007 AHA/ACC/SCAI/ACS/ADA Science Advisory. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients With Coronary Artery Stents. Circulation 2007;115:813-18.
   http://circ.ahajournals.org/cgi/reprint/115/6/813

• Preventing Premature Discontinuation of Antiplatelet Therapy — Download PDF
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