Unstable angina / non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The guidelines below outline the continued recommendations for patients with unstable angina or NSTEMI in regards to stress testing, anticoagulant therapy and antiplatelet therapy. Different guidelines are given on pharmacotherapy depending on the specific situation, such as in the setting of CABG.

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)[1]

Additional Management of Antiplatelets and Anticoagulants (DO NOT EDIT)[1]

Class I
"1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, heart failure, or serious arrhythmias), a stress test should be performed.[2] (Level of Evidence: B)

a) If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed.[3][2] (Level of Evidence: A)

b) If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge[3][2]:

"2. For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.

a) Continue ASA.[18][19][20][21][22][23][24] (Level of Evidence: A)

b) See Class I, #3, in this section.

c) Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG.[18][22][25] (Level of Evidence: B)

d) Anticoagulant therapy should be managed as follows:

"3. In patients taking a P2Y12 receptor inhibitor in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect[9] (Level of Evidence: B). The period of withdrawal should be at least 5 days in patients receiving clopidogrel[9][33] (Level of Evidence: B) or ticagrelor* (Level of Evidence: C) and at least 7 days in patients receiving prasugrel** (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the P2Y12 receptor inhibitor therapy outweighs the potential risks of excess bleeding.[34] (Level of Evidence: C) "
"4. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:

a) Continue aspirin.[4][5][6] (Level of Evidence: A)

b) Administer a loading dose of a P2Y12 receptor inhibitor if not started before diagnostic angiography.[7][35][36][37][38][39] (Level of Evidence: A)

c) Discontinue anticoagulant therapy after PCI for uncomplicated cases.[14][16][40][41][42] (Level of Evidence: B)"

"5. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of coronary atherosclerosis is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Level of Evidence: C)"
"6. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom coronary artery disease was found on angiography, the following approach is recommended:

a) Continue aspirin.[4][5][6] (Level of Evidence: A)

b) Administer a loading dose of clopidogrel or ticagrelor* if not given before diagnostic angiography.[7][9] (Level of Evidence: B)

c) Discontinue IV GP IIb/IIIa inhibitor if started previously.[10][11][43][44] (Level of Evidence: B)

d) Anticoagulant therapy should be managed as follows:

"7. For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:

a) Continue aspirin indefinitely.[4][5][6] (Level of Evidence: A)

b) Continue clopidogrel or ticagrelor* for up to 12 months.[7][9][48][49] (Level of Evidence: B)

c) Discontinue IV GP IIb/IIIa inhibitor if started previously.[10][11] (Level of Evidence: A)

d) Continue UFH for 48 hours[12][13] (Level of Evidence: A) or administer enoxaparin[14][15][16] (Level of Evidence: A) or fondaparinux[17] (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy."

"8. For UA/NSTEMI patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms / ischemia, HF, or serious arrhythmias), Left Ventricular Ejection Fraction should be measured.[3][50][51][52][53] (Level of Evidence: B)"
Class III (No Benefit)
"1. Intravenous fibrinolytic therapy is not indicated in patients without acute ST segment elevation, a true posterior MI, or a presumed new left bundle branch block (LBBB).[54] (Level of Evidence: A)"
Class IIa
"1. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients.[3][55] (Level of Evidence: A)"
"2. For UA/NSTEMI patients in whom PCI is selected as a post angiography management strategy, it is reasonable to omit administration of an intravenous GP IIb/IIIa antagonist if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 h earlier.[3][43] (Level of Evidence: B)"
"3. If Left Ventricular Ejection Fraction is ≤40%, it is reasonable to perform diagnostic angiography.[50][51][52][53] (Level of Evidence: B)"
"4. If Left Ventricular Ejection Fraction is >40%, it is reasonable to perform a stress test.[50] (Level of Evidence: B)"
Class IIb
"1. Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or, after ACS and PCI) on P2Y12 receptor inhibitor therapy may be considered if results of testing may alter management.[56][57][58][59][60] (Level of Evidence: B)"
"2. Genotyping for a CYP2C19 loss of function variant in patients with UA/NSTEMI (or, after ACS and with PCI) on P2Y12 receptor inhibitor therapy might be considered if results of testing may alter management.[61][62][63][64][65][66][67] (Level of Evidence: C)"

* The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily. The benefits of ticagrelor 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 months 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 MI), 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).

References

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