|Drug⁎||Patient Received Initial Medical Treatment (With an Anticoagulant and/or Fibrinolytic Therapy)||Patient Did Not Receive Initial Medical Treatment (With an Anticoagulant and/or Fibrinolytic Therapy)||Comments: All Patients to Receive ASA (162–325 mg)|
|Glycoprotein IIb/IIIa Receptor Antagonists (Section 2)|
|Abciximab||Of uncertain benefit||Continue for up to 12 hours at the discretion of the physician (9,11).|
|Eptifibatide||Of uncertain benefit|
|Tirofiban||Of uncertain benefit|
|Thienopyridines (Section 3)|
|Prasugrel‡||No data are available to guide decision making|
|Parenteral Anticoagulants (Section 4)|
|Bivalirudin||For patients who have received UFH, wait 30 minutes, then give 0.75 mg/kg bolus, then 1.75 mg/kg per hour infusion (Class I, LOE: B)||0.75 mg/kg bolus, 1.75 mg/kg per hour infusion||Bivalirudin may be used to support PCI and STEMI with or without previously administered UFH with the addition of 600 mg of clopidogrel (9). In STEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin anticoagulation is reasonable (9).|
ACT indicates activated clotting time; BMS, bare-metal stent; CABG, coronary artery bypass graft; DES, drug-eluting stent; GP, glycoprotein; IV, intravenous; LD, loading dose; LOE, level of evidence; MACE, major adverse cardiac events; MD, maintenance dose; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIA, transient ischemic attack; and UFH, unfractionated heparin.
↵⁎ This list is in alphabetical order and is not meant to indicate a particular therapy preference. This drug table does not make recommendations for combinations of listed drugs. It is only meant to indicate approved dosages if a drug is chosen for a given situation.
↵† The optimum LD of clopidogrel has not been established. Randomized trials establishing its efficacy and providing data on bleeding risks used an LD of 300 mg orally followed by a daily oral dose of 75 mg (26,27). Higher oral LDs such as 600 mg or more than 900 mg (36) of clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of inhibition of platelet aggregation, but the additive clinical efficacy and safety of higher oral LD have not been rigorously established. For post-PCI patients receiving a DES, a daily MD should be given for at least 12 months unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. For post-PCI patients receiving a BMS, an MD should be given for a minimum of 1 month (28) and ideally up to 12 months (unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine; then it should be given for a minimum of 2 weeks). The necessity for giving an LD of clopidogrel before PCI is driven by the pharmacokinetics of clopidogrel, for which a period of several hours is required to achieve desired levels of platelet inhibition. Patients who have a reduced-function CYP2C19 allele have significantly lower levels of the active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of MACE, including stent thrombosis (53). In STEMI patients taking clopidogrel for whom CABG is planned and can be delayed, it is reasonable to discontinue the clopidogrel to allow for dissipation of the antiplatelet effect, unless the urgency for revascularization and/or the net benefit of clopidogrel outweighs the potential risks of excess bleeding. The period of withdrawal should be at least 5 days in patients receiving clopidogrel (30). Clopidogrel LD after fibrinolytic therapy: For patients given fibrin- and non–fibrin-specific fibrinolytic drugs who are undergoing PCI within 24 hours, 300 mg; for patients given a fibrin-specific fibrinolytic undergoing PCI after more than 24 hours, 300 to 600 mg; for patients given a non–fibrin-specific fibrinolytic undergoing PCI between 24 and 48 hours, 300 mg; for patients given a non–fibrin-specific fibrinolytic undergoing PCI after 48 hours, 300 to 600 mg.
↵‡ 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 MD. Consider lowering the MD to 5 mg in patients who weigh <60 kg. The effectiveness and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients receiving a DES, a daily MD should be given for at least 12 and up to 15 months unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients ≥75 years of age, 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) for 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 days before any surgery. Additional risk factors for bleeding include body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding (e.g., warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal antiinflammatory drugs).