Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy

Acute Coronary Syndrome Main Page
Unstable angina / NSTEMI Microchapters
Home
Patient Information
Overview
Classification
Pathophysiology
Unstable Angina
Non-ST Elevation Myocardial Infarction
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders
Epidemiology and Demographics
Risk Stratification
Natural History, Complications and Prognosis
Special Groups
Women
Heart Failure and Cardiogenic Shock
Perioperative NSTE-ACS Related to Noncardiac Surgery
Stress (Takotsubo) Cardiomyopathy
Diabetes Mellitus
Post CABG Patients
Older Adults
Chronic Kidney Disease
Angiographically Normal Coronary Arteries
Variant (Prinzmetal's) Angina
Substance Abuse
Cardiovascular "Syndrome X"
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Blood Studies
Biomarkers
Electrocardiogram
Chest X Ray
Echocardiography
Coronary Angiography
Treatment
Primary Prevention
Immediate Management
Anti-Ischemic and Analgesic Therapy
Cholesterol Management
Antitplatelet Therapy
Antiplatelet therapy recommendations
Aspirin
Thienopyridines
Glycoprotein IIb/IIIa Inhibitor
Anticoagulant Therapy
Additional Management Considerations for Antiplatelet and Anticoagulant Therapy
Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS
Mechanical Reperfusion
Initial Conservative Versus Initial Invasive Strategies
PCI
CABG
Complications of Bleeding and Transfusion
Discharge Care
Medical Regimen
Post-Discharge Follow-Up
Cardiac Rehabilitation
Long-Term Medical Therapy and Secondary Prevention
ICD implantation within 40 days of myocardial infarction
ICD within 90 days of revascularization
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy
CDC onUnstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy
Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy in the news
Blogs on Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy
to Hospitals Treating Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy
Risk calculators and risk factors for Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update) (DO NOT EDIT)

Convalescent and Long-Term Antiplatelet Therapy (DO NOT EDIT)

Class I

"1. For UA/NSTEMI patients treated medically without stenting, aspirin* should be prescribed indefinitely (Level of Evidence: A); clopidogrel (75 mg per day) or ticagrelor** (90 mg twice daily) should be prescribed for up to 12 months. (Level of Evidence: B) "

"2. For UA/NSTEMI patients treated with a stent (BMS or DES), aspirin should be continued indefinitely. (Level of Evidence: A) The duration and maintenance dose of P2Y12 receptor inhibitor therapy should be as follows: a. Clopidogrel 75 mg daily, prasugrel*** 10 mg daily, or ticagrelor** 90 mg twice daily should be given for at least 12 months in patients receiving DES and up to 12 months for patients receiving BMS. (Level of Evidence: B) b. If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by P2Y12 receptor inhibitor therapy, earlier discontinuation should be considered. (Level of Evidence: C) "

"3. Clopidogrel 75 mg daily (Level of Evidence: A), prasugrel*** 10 mg daily (in PCI-treated patients) (Level of Evidence: C), or ticagrelor 90 mg twice daily (Level of Evidence: C) should be given to patients recovering from UA/NSTEMI when aspirin is contraindicated or not tolerated because of hypersensitivity or GI intolerance (despite use of gastroprotective agents such as PPIs). "

Class III: No Benefit

"1. Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective. (Level of Evidence: B) "

Class IIa

"1. After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses. (Level of Evidence: B) "

Class IIb

"1. For UA/NSTEMI patients who have an indication for anticoagulation, add warfarin to maintain an international normalization ratio of 2.0 to 3.0. (Level of Evidence: B) "

"2. Continuation of a P2Y12 receptor inhibitor beyond 12 months may be considered in patients following DES placement. (Level of Evidence: C) "

* For aspirin-allergic patients, use either clopidogrel or ticagrelor alone (indefinitely) or try aspirin desensitization. Note that there are no data for therapy with 2 concurrent P2Y12 receptor inhibitors, and this is not recommended in the case of aspirin allergy.

** The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily. Ticagrelor's benefits were observed irrespective of prior therapy with clopidogrel. When possible, discontinue ticagrelor at least 5 d before any surgery. Issues of patient compliance may be especially important. Consideration should be given to the potential and as yet undetermined risk of intracranial hemorrhage in patients with prior stroke or TIA.

*** Patients weighing <60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once-daily maintenance dose. Consideration should be given to lowering the maintenance dose to 5 mg in patients who weigh <60 kg, although the effectiveness and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients, a daily maintenance dose should be given for at least 12 mo for patients receiving DES and up to 12 mo for patients receiving BMS unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients age ≥75 y, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit except in high-risk situations (patients with diabetes or a history of prior myocardial infarction), in which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 d before any surgery. Additional risk factors for bleeding include body weight <60 kg, propensity to bleed, and concomitant use of medications that increase the risk of bleeding (eg, warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs).

Related Chapters

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines