Clopidogrel

ST segment elevation MI

Other ACS

• Clopidogrel for patients receiving stents
  • Bare metal - one month
  • Serolimus - three months
  • Paclitaxel - six months
  • Up to 12 months for all without increased bleeding risk.
• Hold clolpidogrel for five to seven days prior to non-emergent coronary artery bypass surgery.
• Clopidogrel for patients receiving thrombolytic therapy who are alergic or have major intolerance to aspirin Class II-a.

• All non-interventional patients without contraindications receive clopidogrel for at least 9 months absent high bleeding risk
• Patients unable to tolerate aspirin due to allergy or major GI disburbance

• Clopidogrel is NOT recommended within 5 days of coronary bypass surgery

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Aspirin

ST segment elevation MI

Other ACS

• Immediately chew ASA162 to 325 mg if not currently receiving ASA.
• Continue ASA at 75 to 162 mg daily indefinitely.
• Pericarditis pain
  • Doses of up to 650 mg (enteric coated) every 4 to 6 hours may be required.
• Clopidogrel is given to patients who cannot take aspirin because of allergy or major GI intolerance.

• Begin aspirin immediately and continue indefinitely
• Substitute Clopidogrel for patients unable to take aspirin due to allergy or MAJOR GI disturbance

Circulation.2000;102:1193 Circulation.2002;106:1893

ST segment elevation MI

Other ACS

• Onset within 12 hours (or 12 to 24 hours with ongling pain. Class II-a)
• ST segment elevation more than 0.1 mV in two or more adjacent leads, or presumed new LBB
• ECG of true posterior MI
• Begin within 90 minutes at facilities without prompt access to PCI lab.

• Thrombolysis is NOT recommended for patients with ischemic symptoms and ST segment depression (except true posterior MI).

• ST-elevation MI more than 24 hours after onset if symptoms have resolved.

• Intracranial risk greater than 4%
  • Treat with PCI

• Thrombolytic treatment is NOT recommended for non-ST segment elevation MI except

  • True Posterior myocardial infarction

  • Presumed new LBBB

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Heparin for STEMI patients treated with thrombolytic agents

• UFH for patients receiving alteplase, retaplase or tenactaplase (selective thrombolytic).
  • Give heparin 60 U/kg iv bolus at onset of alteplase infusion then 12 U/kg/hour (Max = 4,000 U bolus, 1000 U/hour).
  • Adjust infusion to keep aPTT 1.5 to 2.0 times control for 48 hours (II-a).
• Direct antithrombins
  • Patients with heparin-induced thrombocytopenia (Class II-a)
  • bivalirudin 0.25 mg/kg bolus followed by 0.5 mg/kg for 12 hours then 0.25 mg/kg for 36 hours. Reduce bivalirudin infusion rate if PTTY exceeds 75 seconds within the first 12 hours.

• LMWH is of uncertain value as an alternative for UFH. May be used if
  • Patient less than 75 years of age
  • Creatinine less than 2.5 mg/dL for men, less than 2.0 mg/dL for women.
  • Enoxaparin 30 mg IV then 1.0 mg/kg every 12 hours til discharge (Studied with tenacteplase)

Heparin - Unfractionated & LMW

ST elevation MI

Other ACS

• UFH for all patients undergoing percutaneous or surgical revascularization.
• UFH intravenously for patients receiving alteplase, reteplase or tenecteplase.
  • Bolus 60 U/kg (max 4000 U)
  • Infuse 12 U/kg/h (max 1000 U/h)
  • Adjust to PTT 1.5 to 2.0 times control.
• UFH (above doses) for patients at high risk for thromboembolism (large or anterior MI, atrial fibrillation, previous embolus, LV thrombus, or cardiogenic shock).
• UFH (or subcutaneous LMWH) is reasonable (II-a) for 48 hours or until patient is fully ambulatory.
• Monitor platelet counts daily

• Give intravenous unfractionated heparin (UH) or subcutaneous LMWH in addition to ASA or clopidogrel.

• Low molecular weight heparin is preferred (IIa) for patients
  • Without renal failure
  • Not scheduled for coronary bypass within 24 hours

• DVT prophylaxis with subcutaneous UFH or LMWH is of uncertain value with early ambulation and other recommended treatment.

• Intravenous heparin is not recommended during the first six hours after treatment with a nonselective fibrinolytic agent patient is at high thromboembolic risk for systemic embolization.

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Platelet GP IIb/IIIa blockers

ST segment elevation MI

Other ACS

• GP IIb-IIIa antagonist (in addition to ASA and heparin) is given to all patients undergoing percutaneous coronary intervention who have no contraindications

• Eptifibatide or tirofiban should be administered, in addition to ASA and LMWH or UFH, to patients with continuing ischemia, elevated troponin, or other high-risk features when invasive management strategy is not planned. (IIa).

• Tirofiban or eptifibatide may be considered before primary PCI, but there is less evidence than for abciximab.

•  Abciximab is not recommended as the GP IIb-IIIa antagonist for patients who are not undergoing PCI.

Circulation.1999;100:1016
Circulation.2004;110:588

Circulation.2000;102:1193 Circulation.2002;106:1893

Cautions and contraindications to GP IIb/IIIa antagonist therapy

• Active bleeding within 30 days.
• Severe (uncontrolled) hypertension (> 180 - 200 / > 110).
• Major surgery within 6 weeks.
• Any stroke within 30 days (eptifibatide, tirofiban) 2 years (abciximab).
• Hemorrhagic stroke ever.
• Hypersensitivity to drug.
• Use of another IIb/IIIa inhibitor
• Platelet counts less than 100,000 (abciximab, eptifibatide)
• Prior drug-related thrombocytopenia (tirofiban)
• Platelet counts falling to less than 100,000 are an indication for discontinuing both the IIb/IIIa antagonist and heparin (first check at 2 to 4 hours)
• Other considerations
  • Arterial catheters can be removed during GP IIb/IIIa antagonist infusion if heparin has been discontinued and PTT is less than 45 seconds
  • PCI-related heparin is generally discontinued during post-procedure GP IIb/IIIa antgonist infusion