Antiplatelet therapy for STEMI Confirm diagnosis: ST elevation MI LBBB with classical history Fax ECG to infarct centre co-ordinator to arrange immediate primary PCI Confirm diagnosis: ST elevation MI LBBB with classical history Fax ECG to infarct centre co-ordinator to arrange immediate primary PCI Give Aspirin 300mg loading dose/75 mg daily indefinitely, unless contraindicated. If patient over 75, consider coprescription of PPI Give ticagrelor 180mg loading dose (or prasugrel 60mg loading dose) unless contraindicated Immediate PPCI in regional centre Discharge on antiplatelet therapy for 12 months as standard treatment. If patient presents with side effects of antiplatelet therapy contact the responsible consultant cardiologist Selected patients at high risk may be offered clopidogrel 75mg or ticagrelor 60mg bd, for a maximum of three years Selected patients at low risk may be switched from prasugrel/ticagrelor to clopidogrel 75mg one month post MI, for a further 11 months. Notes PPI (proton pump inhibition) should be considered to reduce bleeding risk in older patients on Aspirin. Patients for prolonged antiplatelet use or for earlier switching to clopidogrel should be selected for these alternatives on a case by case basis by the responsible interventional consultant only. Antiplatelet therapy for late presenting STEMI should be same as for those having PPCI. Creatinine levels should be checked within a month after starting ticagrelor Antiplatelets should not be interrupted without prior discussion the responsible consultant cardiologist Patients on warfarin or NOAC should generally be treated in accordance with NICE guidance CG172 NECVN Consensus, July 2017, v 3.2

Antiplatelet therapy in NSTEMI or unstable angina (UA) Make diagnosis: NSTEMI - suggestive history and raised biomarkers (hs troponin preferred) UA - suggestive history and either ongoing chest pain, ECG changes, positive stress test or GRACE risk>1.5% Give Aspirin 300mg loading dose/75 mg daily indefinitely, unless contraindicated. If patient over 75, consider coprescription of PPI Give clopidogrel 600mg loading dose and 75mg daily Review by cardiologist - diagnosis confirmed? YES NO Discontinue clopidogrel Load with ticagrelor 180mg and 90mg b.d. for 12 months, as standard therapy Review need for DAPT, consider alternative diagnosis Selected patients at high risk may be offered clopidogrel 75mg or ticagrelor 60mg bd, for up to three years Selected patients at low risk, or if intolerant to ticagrelor/prasugrel, may switch to clopidogrel 75mg one month post MI, for a further 11 months. Use 300mg loading dose. Notes PPI (proton pump inhibition) should be considered to reduce bleeding risk in older patients on Aspirin. Patients for prolonged antiplatelet use or for earlier switching to clopidogrel should be selected for these alternatives on a case by case basis by the responsible interventional consultant only. Antiplatelets should not be interrupted without prior discussion with the responsible consultant cardiologist Creatinine levels should be checked within a month after starting ticagrelor Aspirin/clopidogrel/rivaroxaban and Aspirin/prasugrel are alternative NICE-approved options in NSTEMI. Patients on warfarin or NOAC should generally be treated in accordance with NICE guidance CG172 NECVN Consensus, July 2017, v3.2