Contraindications to P2Y12 Inhibitors in STEMI and NSTE-ACS

Contraindications and Precautions

The American College of Cardiology recommends that P2Y12 inhibitors should not be administered to patients with a history of stroke or transient ischemic attack (TIA) due to the increased risk of cerebrovascular events (6.5% vs 1.2% with clopidogrel) 1, 3
The European Society of Cardiology advises against the use of prasugrel in patients with active bleeding or a high risk of bleeding 2
The American Heart Association suggests that ticagrelor may be considered in patients with NSTE-ACS who do not undergo early invasive strategy, but prasugrel is preferred in patients who undergo percutaneous coronary intervention (PCI) 2, 4

The American College of Cardiology recommends administering a P2Y12 inhibitor at first medical contact, preferably ticagrelor (180 mg loading dose) or prasugrel (60 mg) if coronary anatomy is known 1, 2
The European Society of Cardiology advises against administering prasugrel before angiography if coronary anatomy is unknown 2, 4

The European Society of Cardiology recommends minimizing the duration of triple therapy (anticoagulant + DAPT) to limit the risk of bleeding 6, 7
The American Heart Association suggests considering a lower INR target (2.0-2.5) when combining DAPT with an anticoagulant 6, 7

The American College of Cardiology recommends interrupting clopidogrel 5 days before elective coronary artery bypass grafting (CABG), prasugrel 7 days before, and ticagrelor 3-5 days before 1, 3
The European Society of Cardiology advises retaking a P2Y12 inhibitor after surgery when the risk of bleeding is not excessive (typically 24-72 hours) 1