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
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.?
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.