Acute Coronary Syndrome Management

Antiplatelet Therapy

• The American College of Cardiology and American Heart Association recommend a loading dose of 300-600 mg clopidogrel, 60 mg prasugrel, or 180 mg ticagrelor as early as possible or at the time of primary percutaneous coronary intervention (PCI) for patients with myocardial infarction (MI) 1, 2, 3, 4
• For primary PCI in STEMI, a loading dose of 600 mg clopidogrel should be administered as early as possible or at the time of PCI, while for PCI after fibrinolytic therapy, a loading dose of 300 mg clopidogrel should be administered if PCI is performed within 24 hours after fibrinolysis, and 600 mg if PCI is performed more than 24 hours after fibrinolysis 1, 5, 3
• Prasugrel should not be given sooner than 24 hours after administration of a fibrin-specific agent and is contraindicated in patients with prior stroke or TIA due to increased risk of intracranial hemorrhage, as recommended by the American College of Cardiology and American Heart Association 1, 5, 3
• For patients with high bleeding risk, consider clopidogrel over prasugrel and bivalirudin over UFH with GP IIb/IIIa inhibitors, as recommended by the American College of Cardiology 1
• Aspirin should be given to all MI patients (150-325 mg oral loading dose) in combination with thienopyridines, as recommended by the European Society of Cardiology 6
• For primary PCI, anticoagulation with unfractionated heparin (100 U/kg or 60 U/kg if GPIIb/IIIa inhibitors are used) is recommended, as recommended by the European Society of Cardiology 6
• If CABG is anticipated, clopidogrel should be discontinued at least 5 days before surgery, and prasugrel should be discontinued at least 7 days before surgery, as recommended by the American Heart Association 3, 7
• For patients aged ≥75 years, prasugrel is generally not recommended due to increased risk of fatal and intracranial bleeding, and for patients with weight <60 kg, consider reducing prasugrel maintenance dose to 5 mg daily due to increased bleeding risk, as recommended by the American Heart Association 7
• Higher loading doses of antiplatelet agents are associated with increased bleeding risk, especially in patients with history of stroke/TIA, low body weight (<60 kg), age ≥75 years, concomitant use of anticoagulants, or recent bleeding events, as reported by the American Heart Association 7

Special Considerations

• Fondaparinux should not be used as the sole anticoagulant for primary PCI due to risk of catheter thrombosis, as recommended by the American College of Cardiology 1
• The use of ticagrelor does not provide significant advantages over clopidogrel in STEMI patients treated with fibrinolytic therapy, according to recent evidence 5

Dosing and Administration