Table 7

Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI

RecommendationsDosing and Special ConsiderationsCORLOEReferences
  • Non–enteric-coated aspirin to all patients promptly after presentation

162 mg–325 mgIA(288–290)
  • Aspirin maintenance dose continued indefinitely

81 mg/d–325 mg/dIA(288–290,293,391)
P2Y12 inhibitors
  • Clopidogrel loading dose followed by daily maintenance dose in patients unable to take aspirin

75 mgIB(291)
  • P2Y12 inhibitor, in addition to aspirin, for up to 12 mo for patients treated initially with either an early invasive or initial ischemia-guided strategy:

    • Clopidogrel

    • Ticagrelor

300-mg or 600-mg loading dose, then 75 mg/d(289,292)
180-mg loading dose, then 90 mg BID(293,294)
  • P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) continued for at least 12 mo in post–PCI patients treated with coronary stents

  • Ticagrelor in preference to clopidogrel for patients treated with an early invasive or ischemia-guided strategy

GP IIb/IIIa inhibitors
  • GP IIb/IIIa inhibitor in patients treated with an early invasive strategy and DAPT with intermediate/high-risk features (e.g., positive troponin)

Preferred options are eptifibatide or tirofibanIIbB(43,94,295)
Parenteral anticoagulant and fibrinolytic therapy
  • SC enoxaparin for duration of hospitalization or until PCI is performed

  • 1 mg/kg SC every 12 h (reduce dose to 1 mg/kg/d SC in patients with CrCl <30 mL/min)

  • Initial 30 mg IV loading dose in selected patients

  • Bivalirudin until diagnostic angiography or PCI is performed in patients with early invasive strategy only

  • Loading dose 0.10 mg/kg loading dose followed by 0.25 mg/kg/h

  • Only provisional use of GP IIb/IIIa inhibitor in patients also treated with DAPT

  • SC fondaparinux for the duration of hospitalization or until PCI is performed

2.5 mg SC dailyIB(312–314)
  • Administer additional anticoagulant with anti-IIa activity if PCI is performed while patient is on fondaparinux

  • IV UFH for 48 h or until PCI is performed

  • Initial loading dose 60 IU/kg (max 4,000 IU) with initial infusion 12 IU/kg/h (max 1,000 IU/ h)

  • Adjusted to therapeutic aPTT range

  • IV fibrinolytic treatment not recommended in patients with NSTE-ACS

N/AIII: HarmA(93,329)

aPTT indicates activated partial thromboplastin time; BID, twice daily; COR, Class of Recommendation; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; GP, glycoprotein; IV, intravenous; LOE, Level of Evidence; max, maximum; N/A, not available; NSTE-ACS, non–ST-elevation acute coronary syndromes; PCI, percutaneous coronary intervention; SC, subcutaneous; and UFH, unfractionated heparin.

See Section for recommendations on antiplatelet/anticoagulant therapy at the time of PCI and Sections 6.2.1 and 6.3 for recommendations on posthospital therapy.

  • The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily (290).