clopidogrel 75 mg per day orally should be added to aspirin in patients with stemi regardless of...

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Page 1: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 2: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 3: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 4: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 5: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 6: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 7: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 8: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 9: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 10: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 11: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 12: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 13: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

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

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Page 16: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

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.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Thienopyridines

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Page 17: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

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)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

*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

Page 18: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

GP IIb-IIIa: the Final Common Pathway to Platelet Aggregation

White HD. Am J Cardiol. 1997; 80(4A):2B-10B.

Page 19: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Braunwald E. et al. ACC/AHA Guidelines. JACC 2000;36:970-1062

Benefit of GP IIb IIIa inhibition among patients with USAP/NSTEMI treated with PCI

across all large trails

Page 20: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

IIb-IIIa Inhibition for NSTEMI

Page 21: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Page 22: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

PRISM,PRISM-Plus,PARAGON A & B,PURSUIT,GUSTO-IVRoffi et al. Circ 2001;104:2767-71

Page 23: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

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.?

Page 24: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Anti-Thrombotics

Page 25: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

ATIIa

Hep

UFH

Page 26: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Oler A et al. JAMA 1996;276:811-815

ASA and UFH vs ASA aloneMeta-analysis of six randomized trails

Page 27: Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI regardless of whether they undergo reperfusion

Unfractionated Heparin

Indirect thrombin inhibitor so does not

inhibit clot-bound thrombin

Nonspecific bindAing to:―Serine AAof HIT

DisadvantagesImmediate

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;103:2994-3018. aPTT = activated partial thromboplastin time; ACT = activated coagulation time; PF-4 = platelet factor 4; HIT = heparin-induced thrombocytopenia.