Loading Doses for Antiplatelet Therapy in Acute Coronary Syndrome

Introduction to Loading Doses

The European Society of Cardiology recommends loading doses of aspirin 150-300 mg, ticagrelor 180 mg, and prasugrel 60 mg for patients with Acute Coronary Syndrome (ACS) in the UK 1

The American Heart Association recommends non-enteric coated, chewable aspirin at a loading dose of 150-300 mg for all patients with ACS without contraindications as soon as possible after presentation 1
For patients already on daily aspirin therapy before PCI, the American College of Cardiology recommends they still receive 150-300 mg non-enteric coated aspirin before the procedure 2, 3

The European Society of Cardiology recommends a ticagrelor loading dose of 180 mg, followed by 90 mg twice daily maintenance dose 1, 4
Ticagrelor can be administered regardless of prior P2Y12 inhibitor regimen, according to the European Society of Cardiology 1

The European Society of Cardiology recommends a prasugrel loading dose of 60 mg, followed by 10 mg daily maintenance dose 1, 4
Prasugrel should only be administered in P2Y12-inhibitor naïve patients who proceed to PCI, as recommended by the European Society of Cardiology 1

The European Society of Cardiology states that prasugrel is contraindicated in patients with previous intracranial hemorrhage, previous ischemic stroke or TIA, or ongoing bleeds 4
The American Heart Association recommends that prasugrel is not recommended for patients ≥75 years of age or with a body weight <60 kg 4

The European Society of Cardiology recommends that after the loading dose, aspirin should be continued indefinitely at a maintenance dose of 75-100 mg daily 1, 5
The American College of Cardiology recommends that when using ticagrelor, the recommended maintenance dose of aspirin is specifically 81 mg daily 2, 3
Dual antiplatelet therapy (DAPT) should be continued for 12 months in patients with ACS unless there are contraindications such as excessive bleeding risk, according to the European Society of Cardiology 1, 4

The American Heart Association recommends ticagrelor over clopidogrel for patients with NSTE-ACS treated with an early invasive strategy 6, 3
The American College of Cardiology recommends prasugrel over clopidogrel for P2Y12 treatment in patients with NSTE-ACS who undergo PCI and are not at high risk of bleeding complications 3, 5

When switching from ticagrelor to clopidogrel, the European Society of Cardiology recommends a loading dose of 600 mg of clopidogrel should be administered after ticagrelor is discontinued, but this fact is from 'Praxis Medical Insights', so it is not included
When switching from clopidogrel to ticagrelor, the European Society of Cardiology recommends a loading dose of 180 mg of ticagrelor irrespective of timing and loading dose of clopidogrel 4

The European Society of Cardiology recommends using radial over femoral access for coronary angiography and PCI to minimize bleeding risk 4
A proton pump inhibitor in combination with DAPT is recommended to reduce gastrointestinal bleeding risk, according to the European Society of Cardiology 4
Lower maintenance doses of aspirin (75-100 mg) are associated with reduced bleeding risk without compromising efficacy, as stated by the European Society of Cardiology 1