Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion.

Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI

regardless of whether they undergo reperfusion with fibrinolytic therapy or do

not receive reperfusion therapy .

Thienopyridines

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

In patients < 75 years who receive fibrinolytic therapy or who do not receive

reperfusion therapy, it is reasonable to administer an oral clopidogrel loading dose of 300 mg. (No data are available to guide decision making regarding an oral loading

dose in patients ≥ 75 years of age.)

Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) can be useful in STEMI patients

regardless of whether they undergo reperfusion with fibrinolytic therapy or do

not receive reperfusion therapy.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Thienopyridines

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Antiplatelet Therapy

For UA/NSTEMI patients treated medically without stenting, aspirin* (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)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

*For ASA-allergic patients, use clopidogrel alone (indefinitely), or try aspirin desensitization.

†For clopidogrel-allergic patients, use ticlopidine 250 mg by mouth twice daily.

See recommendation for LOE

GP IIb-IIIa: the Final Common Pathway to Platelet Aggregation

GP IIb-IIIa: the Final Common Pathway to Platelet Aggregation

White HD. Am J Cardiol. 1997; 80(4A):2B-10B.

Braunwald E. et al. ACC/AHA Guidelines. JACC 2000;36:970-1062

Benefit of GP IIb IIIa inhibition among patients with USAP/NSTEMI treated with PCI

across all large trails

IIb-IIIa Inhibition for NSTEMI

PRISM,PRISM-Plus,PARAGON A & B,PURSUIT,GUSTO-IVRoffi et al. Circ 2001;104:2767-71

Appropriate use of GP IIb IIIa inhibitors Who may benefit the most?

Troponin positive. DM. ACS undergoing PCI.Dynamic ST changes.?Angina refractory to standard medical

therapy.?

Anti-Thrombotics

ATIIa

Hep

UFH

Oler A et al. JAMA 1996;276:811-815

ASA and UFH vs ASA aloneMeta-analysis of six randomized trails

Unfractionated Heparin

Indirect thrombin inhibitor so does not

inhibit clot-bound thrombin

Nonspecific bindAing to:―Serine AAof HIT

DisadvantagesImmediate

anticoagulation

Multiple sites of action in coagulation cascade

Long history of successful clinical use

Readily monitored by aPTT and ACT

Advantages

Hirsh J, et al. Circulation. 2001;103:2994-3018. aPTT = activated partial thromboplastin time; ACT = activated coagulation time; PF-4 = platelet factor 4; HIT = heparin-induced thrombocytopenia.

ATIIa

Hep

UFH

LMWH

AT Xa