Antithrombotic Therapy in Patients Without ST-Segment Elevation

Collet JP, Roffi M, Mueller C, et al.
Questions and Answers on Antithrombotic Therapy: A Companion Document of the 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation. Eur Heart J 2015;Aug 29:[Epub ahead of print].

The following are 10 points to remember about antithrombotic therapy for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation:

  1. Aspirin should be administered as soon as possible in patients with a high likelihood of ACS and low bleeding risk.
  2. Recent data suggest that the duration of dual antiplatelet therapy (DAPT) consisting of aspirin and clopidogrel may be shortened to 3-6 months when bleeding risk is high following drug-eluting stent (DES) implantation.
  3. As the optimal timing of ticagrelor or clopidogrel administration in non–ST elevation ACS patients scheduled for an invasive strategy has not been adequately investigated, no recommendation for or against pretreatment with these agents can be formulated.
  4. Guidelines recommend 1 year of DAPT irrespective of the coronary anatomy.
  5. DAPT beyond 1 year may be recommended in all patients with a first-generation DES. However, no benefit has been evidenced among second-generation DES, the only currently available platforms.
  6. Any prolonged DAPT regimen is associated with an increase in major bleeding that is to be weighed against the estimated reduction in ischemic events.
  7. Morphine delays the biological effect of oral P2Y12 inhibitors by slowing intestinal absorption. The use of glycoprotein IIb/IIIa inhibitors should be considered in those with large visible intracoronary thrombus.
  8. After excluding alternative causes of dyspnea, it is reasonable to stop ticagrelor since dyspnea can be a side effect of the drug. A loading dose of 600 mg clopidogrel 12 hours after the last ticagrelor dosing may be appropriate.
  9. It is appropriate to stop anticoagulation following percutaneous coronary intervention (PCI) in the absence of indications for prolonged/chronic anticoagulation (e.g., mechanical valve, atrial fibrillation, left ventricular thrombus, venous thromboembolic disease, or residual intracoronary thrombus). Accordingly, prolonged parenteral anticoagulation after PCI has never been shown to reduce periprocedural ischemic events, while it increases the risk of bleeding.
  10. Among those with major upper gastrointestinal bleeding treated by interventional endoscopy after successful treatment of the cause of bleeding, DAPT should be resumed. A proton pump inhibitor and monitoring of hemoglobin are indicated.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and ACS, Interventions and ACS

Keywords: Acute Coronary Syndrome, Adenosine, Anticoagulants, Aspirin, Drug-Eluting Stents, Dyspnea, Endoscopy, Fibrinolytic Agents, Hemoglobins, Myocardial Infarction, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Platelet Glycoprotein GPIIb-IIIa Complex, Proton Pump Inhibitors, Thrombosis, Ticlopidine

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