Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Thienopyridines

In patients < 75 years who receive fibrinolytic therapy or who do not receive reperfusion therapy, it is reasonable to administer an oral clopidogrel loading dose of 300 mg. (No data are available to guide decision making regarding an oral loading dose in patients ≥ 75 years of age.) Long-term maintenance therapy (e.g., 1 year) with clopidogrel (75 mg per day orally) can be useful in STEMI patients regardless of whether they undergo reperfusion with fibrinolytic therapy or do not receive reperfusion therapy. Thienopyridines

Antiplatelet Therapy For UA/NSTEMI patients treated medically without stenting, aspirin* (75 to 162 mg per day) should be prescribed indefinitely (Level of Evidence: A); clopidogrel† (75 mg per day) should be prescribed for at least 1 month (Level of Evidence: A) and ideally for up to 1 year. (Level of Evidence: B) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III *For ASA-allergic patients, use clopidogrel alone (indefinitely), or try aspirin desensitization. †For clopidogrel-allergic patients, use ticlopidine 250 mg by mouth twice daily. See recommendation for LOE

GP IIb-IIIa: the Final Common Pathway to Platelet Aggregation White HD. Am J Cardiol. 1997; 80(4A):2B-10B.

Braunwald E. et al. ACC/AHA Guidelines. JACC 2000;36: Benefit of GP IIb IIIa inhibition among patients Benefit of GP IIb IIIa inhibition among patients with USAP/NSTEMI treated with PCI with USAP/NSTEMI treated with PCI across all large trails

IIb-IIIa Inhibition for NSTEMI

PRISM,PRISM-Plus,PARAGON A & B,PURSUIT,GUSTO-IV Roffi et al. Circ 2001;104:

Appropriate use of GP IIb IIIa inhibitors Who may benefit the most? Troponin positive. DM. ACS undergoing PCI. Dynamic ST changes?. Angina refractory to standard medical therapy?.

Anti-Thrombotics

AT IIa Hep UFH

Oler A et al. JAMA 1996;276: ASA and UFH vs ASA alone Meta-analysis of six randomized trails

Unfractionated Heparin  Indirect thrombin inhibitor so does not inhibit clot-bound thrombin  Nonspecific bindAing to: ― Serine AAof HIT Disadvantages  Immediate anticoagulation  Multiple sites of action in coagulation cascade  Long history of successful clinical use  Readily monitored by aPTT and ACT Advantages Hirsh J, et al. Circulation. 2001;103: aPTT = activated partial thromboplastin time; ACT = activated coagulation time; PF-4 = platelet factor 4; HIT = heparin-induced thrombocytopenia.

AT IIa Hep UFH LMWH AT Xa