Table 3

Adjunctive Antithrombotic Therapy to Support Reperfusion With Primary PCI

CORLOEReferences
Antiplatelet therapy
Aspirin
• 162- to 325-mg load before procedureIB(251–253)
• 81- to 325-mg daily maintenance dose (indefinite)IA(254,255,257)
• 81 mg daily is the preferred maintenance doseIIaB(253,254,263,264)
P2Y12inhibitors
 Loading doses
• Clopidogrel: 600 mg as early as possible or at time of PCIIB(253,258,259)
• Prasugrel: 60 mg as early as possible or at time of PCIIB(260)
• Ticagrelor: 180 mg as early as possible or at time of PCIIB(261)
 Maintenance doses and duration of therapy
DES placed: Continue therapy for 1 y with:
• Clopidogrel: 75 mg dailyIB(260,262)
• Prasugrel: 10 mg dailyIB(262)
• Ticagrelor: 90 mg twice a dayIB(261)
BMSplaced: Continue therapy for 1 y with:
• Clopidogrel: 75 mg dailyIB(260,262)
• Prasugrel: 10 mg dailyIB(262)
• Ticagrelor: 90 mg twice a dayIB(261)
DES placed:
• Clopidogrel, prasugrel, or ticagrelor continued beyond 1 yIIbCN/A
• Patients with STEMI with prior stroke or TIA: prasugrelIII: HarmB(260)
IV GP IIb/IIIa receptor antagonists in conjunction with UFH or bivalirudin in selected patients
• Abciximab: 0.25-mg/kg IV bolus, then 0.125 mcg/kg/min (maximum 10 mcg/min)IIaA(265–267)
• Tirofiban: (high-bolus dose): 25-mcg/kg IV bolus, then 0.15 mcg/kg/minIIaB(268,269)
 • In patients with CrCl <30 mL/min, reduce infusion by 50%
• Eptifibatide: (double bolus): 180-mcg/kg IV bolus, then 2 mcg/kg/min; a second 180-mcg/kg bolus is administered 10 min after the first bolusIIaB(270)
 • In patients with CrCl <50 mL/min, reduce infusion by 50%
 • Avoid in patients on hemodialysis
• Pre–catheterization laboratory administration of IV GP IIb/IIIa receptor antagonistIIbB(103,268,271–277)
• Intracoronary abciximab 0.25-mg/kg bolusIIbB(223,278–284)
Anticoagulant therapy
• UFH:ICN/A
 • With GP IIb/IIIa receptor antagonist planned: 50- to 70-U/kg IV bolus to achieve therapeutic ACT
 • With no GP IIb/IIIa receptor antagonist planned: 70- to 100-U/kg bolus to achieve therapeutic ACT§ICN/A
  • • Bivalirudin: 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion with or without prior treatment with UFH. An additional bolus of 0.3 mg/kg may be given if needed.

  •  • Reduce infusion to 1 mg/kg/h with estimated CrCl <30 mL/min

IB(248)
 • Preferred over UFH with GP IIb/IIIa receptor antagonist in patients at high risk of bleedingIIaB(248)
• Fondaparinux: not recommended as sole anticoagulant for primary PCIIII: HarmB(304)

ACT indicates activated clotting time; BMS, bare-metal stent; CrCl, creatinine clearance; COR, Class of Recommendation; DES, drug-eluting stent; GP, glycoprotein; IV, intravenous; LOE, Level of Evidence; N/A, not available; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; TIA, transient ischemic attack; and UFH, unfractionated heparin.

  • The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

  • Balloon angioplasty without stent placement may be used in selected patients. It might be reasonable to provide P2Y12 inhibitor therapy to patients with STEMI undergoing balloon angioplasty alone according to the recommendations listed for BMS. (LOE: C).

  • The recommended ACT with planned GP IIb/IIIa receptor antagonist treatment is 200 to 250 s.

  • § The recommended ACT with no planned GP IIb/IIIa receptor antagonist treatment is 250 to 300 s (HemoTec device) or 300 to 350 s (Hemochron device).