ACC/AHA recommendations for initial antiplatelet therapy for patients with likely or definite non-ST-elevation myocardial infarction
| Antiplatelet drug | Initial therapy (class of recommendation, level of evidence)a | Continued therapy (class of recommendation, level of evidence)a |
|---|---|---|
| General recommendations for non-ST-elevation myocardial infarction | ||
| Aspirin | 162–325 mg of nonenteric coated aspirin for all patients promptly after presentation (I, A) | 81–162 mg/day indefinitely as maintenance dose (I, A) |
| P2Y12 inhibitors | 300–600 mg loading dose clopidogrel in patients with gastrointestinal intolerance or aspirin hypersensitivity (I, B) 300–600 mg loading dose of clopidogrel or 180 mg loading dose of ticagrelor in addition to aspirin in patients treated with an early invasive or ischemiaguided strategy (I, B) It is reasonable to use ticagrelor in preference to clopidogrel for patients treated with an early invasive or ischemia-guided strategy (IIa, B) | Clopidogrel 75 mg/day as maintenance dose in patients with gastrointestinal intolerance or aspirin hypersensitivity (I, B) Clopidogrel 75 mg/day or ticagrelor 90 mg twice daily in addition to aspirin as maintenance dose for up to 12 months in patients treated with an early invasive or ischemia-guided strategy (I, B) |
| Recommendations for percutaneous coronary intervention (PCI) | ||
| Aspirin | 81–325 mg nonenteric coated aspirin before PCI in patients already taking aspirin (I, B) 325 mg nonenteric coated aspirin as soon as possible before PCI in patients not taking aspirin (I, B) | 81–325 mg/day to be continued indefinitely after PCI (I, B) It is reasonable to use 81 mg/day in preference to a higher maintenance dose (IIa, B) |
| P2Y12 inhibitors | A loading dose before PCI in patients undergoing stenting (I, A): Clopidogrel 300–60 mg (I, B) or Prasugrel 60 mg (I, B) or Ticagrelor 180 mg (I, B) It is reasonable to use ticagrelor in preference to clopidogrel for patients treated with an early invasive strategy or coronary stenting (IIa, B) It is reasonable to use prasugrel in preference to clopidogrel for patients who undergo PCI and are not at high risk of bleeding (IIa, B) Prasugrel should not be given to patients with a history of stroke or transient ischemic attack (III, B) | Maintenance dose to be continued for at least 12 months in patients receiving a bare-metal or drugeluting stent. Options include: Clopidogrel 75 mg/day (I, B) or Prasugrel 10 mg/day (I B) or Ticagrelor 90 mg twice a day (I, B) If the morbidity of bleeding outweighs the anticipated benefit of duration of P2Y12 inhibitor therapy after stent implantation, early discontinuation (ie, < 12 months) of P2Y12 therapy is reasonable (IIa, C) Continuation of dual antiplatelet therapy beyond 12 months may be considered in patients undergoing stent implantation (IIb, C) |
↵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.
Based on information in reference 2.