|Drug⁎||During PCI||Comments ▶ All Patients to Receive ASA|
|Patient Received Initial Medical Treatment (With a P2Y12 Receptor Inhibitor)||Patient Did Not Receive Initial Medical Treatment (With a P2Y12 Receptor Inhibitor)|
|Glycoprotein IIb/IIIa Receptor Antagonists|
|Abciximab||Of uncertain benefit||▶ Continue for up to 12 h at the discretion of the physician.|
|Eptifibatide||Of uncertain benefit|
|Tirofiban||Of uncertain benefit|
|P2Y12 Receptor Inhibitors|
|Prasugrel‡||No data are available to guide decision making|
|Ticagrelor||Patients who are already receiving clopidogrel should receive a loading dose of ticagrelor|
|Bivalirudin||For patients who have received UFH, wait 30 min, then give 0.75 mg/kg bolus, then 1.75 mg/kg per h infusion (Class I, LOE: B)||0.75 mg/kg bolus, 1.75 mg/kg per h infusion|
Modified from Wright et al (6).
ACT indicates activated clotting time; ASA, aspirin; BMS, bare-metal stent; CABG, coronary artery bypass graft; DES, drug-eluting stent; GP, glycoprotein; FDA, Food and Drug Administration; ICH, intracranial hemorrhage; IV, intravenous; LD, loading dose; LOE, level of evidence; MACE, major adverse cardiac events; MD, maintenance dose; PCI, percutaneous coronary intervention; PLATO, PLATelet inhibition and patient Outcomes trial; PPI, proton pump inhibitor; STEMI, ST-elevation myocardial infarction; TIA, transient ischemic attack; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; 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 an approved or recommended dosage 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. Higher oral LDs such as 600 mg or more than 900 mg 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 mo unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor. For post-PCI patients receiving a BMS, an MD should be given for up to 12 mo (unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor; then it should be given for a minimum of 2 wk). 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. In UA/NSTEMI 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 outweigh the potential risks of excess bleeding. The period of withdrawal should be at least 5 d in patients receiving clopidogrel.
↵‡ 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 DES, a daily MD should be given for at least 12 mo 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), 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 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 (e.g., warfarin, heparin, fibrinolytic therapy, or long-term use of nonsteroidal anti-inflammatory drugs).