ACC/AHA recommendations for antiplatelet therapy for patients with ST-elevation myocardial infarction (STEMI)
| Antiplateletdrug | Initial therapy (class of recommendation, level of evidence)a | Continued therapy (class of recommendation, level of evidence)a |
|---|---|---|
| Antiplatelet therapy adjunctive to primary percutaneous coronary intervention (PCI) | ||
| Aspirin | 162–325 mg should be given to all patients before primary PCI (I, B) | 81–325 mg maintenance dose indefinitely (I, A) 81 mg as preferred maintenance dose with ticagrelor (I, B) |
| P2Y12 inhibitors | Loading dose should be given as early as possible or at the time of primary PCI in patients with STEMI. Options: Clopidogrel 300–600 mg (I, B) Prasugrel 60 mg (I, B) Ticagrelor 180 mg (I, B) | Maintenance dose should be continued for 1 year following a drug-eluting or bare metal stent placement. Options: Clopidogrel 75 mg daily (I, B) Prasugrel 10 mg daily (I, B) Ticagrelor 90 mg twice daily (I, B) |
| Prasugrel should not be given to patients with a history of stroke or transient ischemic attack (III, B) | Continuation of P2Y12 inhibitor beyond 1 year may be considered in patients with drug-eluting stent placement (IIb, C) | |
| Antiplatelet therapy adjunctive to PCI after fibrinolytic therapy | ||
| Aspirin | 162–325 mg should be given to all patients who receive fibrinolytic therapy (I, A) | 81–325 mg maintenance dose indefinitely (I, A) 81 mg is preferred maintenance dose (IIa, B) |
| P2Y12 inhibitors | Clopidogrel loading dose based on age in all patients who receive fibrinolytic therapy (I, A) Age ≤ 75: 300 mg Age > 75: 75 mg | If drug-eluting stent placed: Continue P2Y12 inhibitor for at least 1 year with either: Clopidogrel 75 mg daily (I, C) Prasugrel 10 mg daily (IIa, B) |
| For patients who received loading dose during fibrinolytic therapy: clopidogrel 75 mg daily without an additional loading dose (I, C) | If bare-metal stent placedb: Continue therapy for at least 30 days and up to 1 year with either of the following: Clopidogrel 75 mg daily (I, C) Prasugrel 10 mg daily (IIa, B) | |
| For patients who did not receive loading dose during fibrinolytic therapy: | ||
| If PCI performed ≤ 24 hours after fibrinolytic therapy: clopidogrel 300 mg before or at the time of PCI (I, C) | ||
| If PCI performed > 24 hours after fibrinolytic therapy: clopidogrel 600 mg before or at the time of PCI (I, C) | ||
| If PCI performed > 24 hours after treatment with a fibrinspecific agent or > 48 hours after a non–fibrin-specific agent: prasugrel 60 mg at the time of PCI (IIa, B) | ||
| Prasugrel should not be given to patients with a history of stroke or transient ischemic attack (III, B) | ||
↵a Class of recommendation: I = treatment should be given, IIa = treatment is reasonable, IIb = treatment may be considered, III = treatment is not recommended or may harm. Level of evidence: A = multiple populations evaluated, B = limited populations evaluated, C = very limited populations evaluated.
↵b Balloon angioplasty without stent placement may be used in selected patients. It may be reasonable to provide P2Y12 inhibitor therapy to patients with ST-elevation myocardial infarction undergoing balloon angioplasty after fibrinolysis alone according to the recommendations listed for bare-metal stents (level of evidence C).
Based on information in reference 1.