Recommendations for Additional Management of Antiplatelet and Anticoagulant Therapy
| 2007 Recommendations | 2011 Focused Update Recommendations | Comments |
|---|---|---|
| Class I | ||
For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), a stress test should be performed. (Level of Evidence: B) (Fig. 8; Box O)
| 1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), a stress test should be performed.26 (Level of Evidence: B)
| Modified recommendation (changed level of evidence from A to B for 1-month clopidogrel administration; clarified levels of evidence for UFH, enoxaparin, and fondaparinux). |
For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box G).
| 2. For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.
| Modified recommendation (changed item “b” to include prasugrel and be a stand-alone recommendation; see Class I, #3, in this section). |
| For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box G). b. Discontinue clopidogrel 5 to 7 days before elective CABG. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C) | 3. In patients taking a thienopyridine in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect13 (Level of Evidence: B) The period of withdrawal should be at least 5 days in patients receiving clopidogrel13,18,59 (Level of Evidence: B) and at least 7 days in patients receiving prasugrel*35 (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding.60 (Level of Evidence: C) | Modified recommendation (changed to include prasugrel and update length of withdrawal period; from Class I, #2, in this section). |
For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box H):
| 4. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
| Modified recommendation (included language to allow for prasugrel as choice of thienopyridine; class of item “c” changed from I to IIa). |
| For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of coronary atherosclerosis is present (eg, luminal irregularities or intravascular ultrasound-demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Fig. 9; Box I) (Level of Evidence: C) | 5. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of coronary atherosclerosis is present (eg, luminal irregularities or intravascular ultrasound-demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Level of Evidence: C) | 2007 recommendation remains current. |
For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom CAD was found on angiography, the following approach is recommended (Fig. 9; Box J):
| 6. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom CAD was found on angiography, the following approach is recommended:
| Modified recommendation (changed level of evidence from A to B for clopidogrel loading dose). |
For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed (Fig. 8; Box K):
| 7. For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:
| Modified recommendation (changed level of evidence from A to B for 1-month clopidogrel administration). |
| For UA/NSTEMI patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), LVEF should be measured. (Level of Evidence: B) (Fig. 8; Box L) | 8. For UA/NSTEMI patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), LVEF should be measured.25,69–72 (Level of Evidence: B) | 2007 recommendation remains current. |
| Class IIa | ||
| 1. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients.25,27 (Level of Evidence: A) | Modified recommendation (see Class I, #4, in this section). | |
| For UA/NSTEMI patients in whom PCI is selected as a management strategy, it is reasonable to omit administration of an IV GP IIb/IIIa antagonist if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier. (Level of Evidence: B) (Fig. 9) | 2. For UA/NSTEMI patients in whom PCI is selected as a management strategy, it is reasonable to omit administration of an IV GP IIb/IIIa inhibitor if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier.16,25 (Level of Evidence: B) | 2007 recommendation remains current. |
| If LVEF is ≤0.40, it is reasonable to perform diagnostic angiography. (Level of Evidence: B) (Fig. 8; Box M) | 3. If LVEF is ≤0.40, it is reasonable to perform diagnostic angiography.69–72 (Level of Evidence: B) | 2007 recommendation remains current. |
| If LVEF is greater than 0.40, it is reasonable to perform a stress test. (Level of Evidence: B) (Fig. 8; Box N) | 4. If LVEF is greater than 0.40, it is reasonable to perform a stress test.69 (Level of Evidence: B) | 2007 recommendation remains current. |
| Class IIb | ||
| For UA/NSTEMI patients in whom PCI is selected as a management strategy, it may be reasonable to omit an IV GP IIb/IIIa inhibitor if not started before diagnostic angiography for troponin-negative patients without other clinical or angiographic high-risk features. (Level of Evidence: C) | Deleted recommendation | |
| 1. Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or, after ACS and PCI) on thienopyridine therapy may be considered if results of testing may alter management.73–77 (Level of Evidence: B) | New recommendation | |
| 2. Genotyping for a CYP2C19 loss of function variant in patients with UA/NSTEMI (or, after ACS and with PCI) on clopidogrel therapy might be considered if results of testing may alter management.78–84 (Level of Evidence: C) | New recommendation | |
| Class III: No Benefit | ||
| IV fibrinolytic therapy is not indicated in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block. (Level of Evidence: A) | 1. IV fibrinolytic therapy is not indicated in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block.85 (Level of Evidence: A) | 2007 recommendation remains current. |
* 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 receiving a bare-metal stent (BMS) or drug-eluting stent (DES), a daily maintenance dose should be given for at least 12 months and for 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), 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 days before any surgery.35 Additional risk factors for bleeding include body weight <60 kg, propensity to bleed, and concomitant use of medications that increase the risk of bleeding (eg, warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs).35