Table 5.

Recommendations for Convalescent and Long-Term Antiplatelet Therapy

2007 Recommendations	2011 Focused Update Recommendations	Comments
Class I
For UA/NSTEMI patients treated medically without stenting, ASA^* (75 to 162 mg per day) should be prescribed indefinitely (Level of Evidence: A); clopidogrel^† (75 mg per day) should be prescribed for at least 1 month (Level of Evidence: A) and ideally for up to 1 year. (Level of Evidence: B)	1. For UA/NSTEMI patients treated medically without stenting, ASA^* (75 to 162 mg per day) should be prescribed indefinitely^4,6,9,10 (Level of Evidence: A); clopidogrel^† (75 mg per day) should be prescribed for at least 1 month¹³ and ideally up to 1 year.^13,121 (Level of Evidence: B)	Modified recommendation (level of evidence changed from A to B for 1-month duration of clopidogrel).
For UA/NSTEMI patients treated with a BMS, ASA^* 162 to 325 mg per day should be prescribed for at least 1 month (Level of Evidence: B), then continued indefinitely at a dose of 75 to 162 mg per day (Level of Evidence: A); clopidogrel should be prescribed at a dose of 75 mg per day for a minimum of 1 month and ideally for up to 1 year (unless the patient is at increased risk of bleeding; then it should be given for a minimum of 2 weeks). (Level of Evidence: B)	2. For UA/NSTEMI patients treated with a BMS, ASA^* 162 to 325 mg per day should be prescribed for at least 1 month (Level of Evidence: B), then continued indefinitely at a dose of 75 to 162 mg per day. (Level of Evidence: A) The duration and maintenance dose of thienopyridine therapy should be as follows: clopidogrel 75 mg daily¹⁷ or prasugrel 10 mg daily²² should be given for at least 12 months.^13,17 (Level of Evidence: B) If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by thienopyridine therapy, earlier discontinuation should be considered. (Level of Evidence: C)	Modified recommendation (to be concordant with 2009 STEMI and PCI Focused Update).³²
For UA/NSTEMI patients treated with a DES, ASA^* 162 to 325 mg per day should be prescribed for at least 3 months after sirolimus-eluting stent implantation and 6 months after paclitaxel-eluting stent implantation, then continued indefinitely at a dose of 75 to 162 mg per day. (Level of Evidence: B) Clopidogrel 75 mg daily should be given for at least 12 months to all post-PCI patients receiving DES. (Level of Evidence: B)	3. For UA/NSTEMI patients treated with a DES, ASA^* 162 to 325 mg per day should be prescribed for at least 3 months after sirolimus-eluting stent implantation and 6 months after paclitaxel-eluting stent implantation (Level of Evidence: B), then continued indefinitely at a dose of 75 to 162 mg per day. (Level of Evidence: A). The duration and maintenance dose of thienopyridine therapy should be as follows: clopidogrel 75 mg daily¹⁷ or prasugrel 10 mg daily²² should be given for at least 12 months.^13,17 (Level of Evidence: B) If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by thienopyridine therapy, earlier discontinuation should be considered. (Level of Evidence: C)	Modified recommendation (to be concordant with 2009 STEMI and PCI Focused Update.³²
Clopidogrel 75 mg daily (preferred) or ticlopidine (in the absence of contraindications) should be given to patients recovering from UA/NSTEMI when ASA is contraindicated or not tolerated because of hypersensitivity or gastrointestinal intolerance (but with gastroprotective agents such as PPIs). (Level of Evidence: A)	4. Clopidogrel 75 mg daily (preferred) or ticlopidine (in the absence of contraindications) should be given to patients recovering from UA/NSTEMI when ASA is contraindicated or not tolerated because of hypersensitivity or GI intolerance (despite use of gastroprotective agents such as PPIs).^{11–13,61,108} (Level of Evidence: B)	Modified recommendation (changed wording for clarity; level of evidence changed from A to B because trials do not address the specific subgroups in this recommendation).
Class IIa
For UA/NSTEMI patients in whom the physician is concerned about the risk of bleeding, a lower initial ASA dose after PCI of 75 to 162 mg per day is reasonable. (Level of Evidence: C)	1. For UA/NSTEMI patients in whom the physician is concerned about the risk of bleeding, a lower initial ASA dose (75 to 162 mg/day) after PCI is reasonable. (Level of Evidence: C)	2007 recommendation remains current.
Class IIb
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.^§ (Level of Evidence: B)	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.^§^122–131 (Level of Evidence: B)	2007 recommendation remains current.
	2. Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients following DES placement. (Level of Evidence: C)	New recommendation (to be concordant with 2009 STEMI and PCI Focused Update.³²)
Class III: No Benefit
Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective. (Level of Evidence: A)	1. Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective.^44,132,133 (Level of Evidence: B)	Modified recommendation (level of evidence changed from A to B).

* For ASA-allergic patients, use clopidogrel alone (indefinitely) or try ASA desensitization.
† For clopidogrel-allergic patients, use ticlopidine 250 mg by mouth twice daily.
‡ Continue ASA 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 ASA and clopidogrel, 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).