|2012 Focused Update Recommendations||2012 Comments|
|1. For UA/NSTEMI patients treated medically without stenting, aspirin⁎ should be prescribed indefinitely (60,61,63,64) (Level of Evidence: A); clopidogrel (75 mg per day) or ticagrelor† (90 mg twice daily) should be prescribed for up to 12 months (9,10,14). (Level of Evidence: B)||2011 recommendation modified (included ticagrelor and footnote added pertaining to recommended aspirin maintenance dose).|
|2. For UA/NSTEMI patients treated with a stent (BMS or DES), aspirin should be continued indefinitely. (Level of Evidence: A) The duration and maintenance dose of P2Y12 receptor inhibitor therapy should be as follows:||2011 recommendation modified (included the term “P2Y12 receptor inhibitor” and altered aspirin dosing and duration of therapy after stent deployment).|
|a. Clopidogrel 75 mg daily (16), prasugrel‡ 10 mg daily (7), or ticagrelor† 90 mg twice daily (9) should be given for at least 12 months in patients receiving DES and up to 12 months for patients receiving BMS (9,13,16). (Level of Evidence: B)|
|b. If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by P2Y12 receptor inhibitor therapy, earlier discontinuation should be considered. (Level of Evidence: C)|
|3. Clopidogrel 75 mg daily (13,67) (Level of Evidence: B), prasugrel‡ 10 mg daily (in PCI-treated patients) (7) (Level of Evidence: C), or ticagrelor† 90 mg twice daily (9) (Level of Evidence: C) should be given to patients recovering from UA/NSTEMI when aspirin is contraindicated or not tolerated because of hypersensitivity or GI intolerance (despite use of gastroprotective agents such as PPIs) (42,68).||2011 recommendation modified (included prasugrel and ticagrelor; deleted ticlopidine).|
|1. After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses (32,33,90,127,128). (Level of Evidence: B)||2011 recommendation modified (changed wording and aspirin dose to be concordant with the 2011 PCI guideline ).|
|1. For UA/NSTEMI patients who have an indication for anticoagulation, the addition of warfarin§ may be reasonable to maintain an INR of 2.0 to 3.0∥ (129–138). (Level of Evidence: B)||2007 recommendation remains current.|
|2. Continuation of a P2Y12 receptor inhibitor beyond 12 months may be considered in patients following DES placement. (Level of Evidence: C)||2011 recommendation modified (changed time period to be concordant with 2011 PCI guideline  and replaced “clopidogrel and prasugrel” with “P2Y12 receptor inhibitor”).|
|Class III: No Benefit|
|1. Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective (90,139,140). (Level of Evidence: B)||2011 recommendation remains current.|
BMS indicates bare-metal stent; CABG, coronary artery bypass graft; DES, drug-eluting stent; GI, gastrointestinal; INR, international normalized ratio; LV, left ventricular; PCI, percutaneous coronary intervention; PPI, proton pump inhibitor; TIA, transient ischemic attack; and UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction.
↵⁎ For aspirin-allergic patients, use either clopidogrel or ticagrelor alone (indefinitely) or try aspirin desensitization. Note that there are no data for therapy with 2 concurrent P2Y12 receptor inhibitors, and this is not recommended in the case of aspirin allergy.
↵† The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily (11). Ticagrelor's benefits were observed irrespective of prior therapy with clopidogrel (9). When possible, discontinue ticagrelor at least 5 d before any surgery (12). 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 mo 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 myocardial infarction), 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 (8). 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 chronic use of nonsteroidal anti-inflammatory drugs) (8).
↵§ Continue aspirin indefinitely and warfarin longer term as indicated for specific conditions such as atrial fibrillation; LV thrombus; or cerebral, venous, or pulmonary emboli.
↵∥ An INR of 2.0 to 2.5 is preferable while given with aspirin and a P2Y12 receptor inhibitor, especially in older patients and those with other risk factors for bleeding. For UA/NSTEMI patients who have mechanical heart valves, the INR should be at least 2.5 (based on type of prosthesis).