Abstract
Résumé
Updated Evidence for Antiplatelet Therapy After ACS in Patients Treated With PCI, CABG, or Medical Therapy Alone
Optimal acetylsalicylic acid dose after ACS
Platelet P2Y12 receptor antagonists
Clopidogrel
Prasugrel
- Montalescot G.
- Bolognese L.
- Dudek D.
- et al.
Ticagrelor
- Steg P.G.
- James S.
- Harrington R.A.
- et al.
Updated Data for Antiplatelet Therapy for Secondary Prevention in the First Year After PCI
Optimal duration of dual antiplatelet therapy after stent implantation
- Mauri L.
- Kereiakes D.J.
- Normand S.L.
- et al.
- 1.We recommend ASA 81 mg daily indefinitely in all patients with NSTEACS (Strong Recommendation, High-Quality Evidence).
- 2.We recommend ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in patients with moderate to high risk NSTEACS (as defined in PLATO16: ≥2 or more of (1) ischemic ST changes on electrocardiogram; (2) positive biomarkers; or (3) 1 of the following: 60 years of age or greater, previous MI or CABG, CAD > 50% stenosis in 2 vessels, previous ischemic stroke, diabetes, peripheral arterial disease, or chronic renal dysfunction), managed with either PCI, CABG surgery, or medical therapy alone (Strong Recommendation, High-Quality Evidence).
- 3.We recommend prasugrel 10 mg daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in P2Y12 inhibitor-naive patients with NSTEACS after their coronary anatomy has been defined and PCI planned (Strong Recommendation, High-Quality Evidence).
- 4.We recommend avoiding prasugrel in patients with previous TIA or stroke or in patients who are not treated with PCI. Except in patients with a high probability of undergoing PCI, we recommend avoiding prasugrel before the coronary anatomy has been defined (Strong Recommendation, Moderate-Quality Evidence).
- 5.We recommend clopidogrel 75 mg once daily for 12 months in addition to ASA 81 mg daily in patients with NSTEACS managed with either PCI, CABG, or medical therapy and who are not eligible for ticagrelor or prasugrel (Strong Recommendation, High-Quality Evidence).
- 6.We recommend that in patients in whom clopidogrel is to be used, a higher maintenance dose of 150 mg daily be considered for the first 6 days in patients with NSTEACS treated with PCI (Strong Recommendation, Moderate-Quality Evidence).


- 1.We recommend clopidogrel 75 mg daily for at least 1 month in addition to ASA 81 mg daily in patients with STEMI who were managed with either fibrinolytic therapy or no reperfusion therapy (Strong Recommendation, High-Quality Evidence). We suggest that clopidogrel can be continued for 12 months (Conditional Recommendation, Low-Quality Evidence).
- 2.We recommend either prasugrel 10 mg daily or ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI (Strong Recommendation, Moderate-Quality Evidence).
- 3.We recommend clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI in patients who are not eligible for prasugrel or ticagrelor (Strong Recommendation, Moderate-Quality Evidence).
- 4.We recommend that in patients in whom clopidogrel is to be used, a higher maintenance dose of 150 mg daily be considered for the first 6 days in patients with STEMI treated with PCI (Strong Recommendation, Moderate-Quality Evidence).
- 5.We recommend avoiding prasugrel in patients with previous TIA or stroke and using a 5-mg dose if required in patients aged years or older or weight ≤ 60 kg (Strong Recommendation, Low-Quality Evidence).

- 1.We recommend that in patients receiving a bare-metal stent who are unable to tolerate clopidogrel for 12 months (eg, increased risk of bleeding or scheduled noncardiac surgery), the minimum duration of therapy should be 1 month (Strong Recommendation, High-Quality Evidence). We suggest in patients at very high risk of bleeding, the minimum duration of treatment may be 2 weeks (Conditional Recommendation, Low-Quality Evidence).
- 2.We suggest that in patients receiving a second-generation DES who are unable to tolerate clopidogrel for 12 months (eg, increased risk of bleeding or scheduled noncardiac surgery), the minimum duration of therapy may be 3 months (Conditional Recommendation, Low-Quality Evidence).
- 1.We recommend that for patients who are compliant with clopidogrel and have experienced stent thrombosis, prasugrel 10 mg daily or ticagrelor 90 mg twice daily may be considered in addition to ASA 81 mg daily (Strong Recommendation, Low-Quality Evidence).
- 2.We suggest continuation of a P2Y12 inhibitor with ASA beyond 12 months be considered in patients with a high thrombosis risk and a low bleeding risk (Conditional Recommendation, Low-Quality Evidence).
- 3.We suggest that if patients require surgery (CABG or non-CABG), the P2Y12 inhibitor be withheld, if possible, as follows: clopidogrel 5 days before, ticagrelor 5 days before, and prasugrel 7 days before to the date of surgery (Conditional Recommendation, Low-Quality Evidence).
- 4.We suggest against switching the P2Y12 inhibitor initially selected at discharge unless there is a compelling clinical reason (eg, stent thrombosis, bleeding, or cardiovascular event) (Conditional Recommendation, Very Low-Quality Evidence).
What Is the Optimal Antiplatelet Therapy Regimen After CABG?
- Eagle K.A.
- Guyton R.A.
- Davidoff R.
- et al.
- Fox K.A.
- Mehta S.R.
- Peters R.
- et al.
- 1.We recommend that in patients with ACS requiring CABG, the risk of bleeding vs the benefit of continuing DAPT be weighed in deciding the appropriate timing of intervention (Strong Recommendation, Low-Quality Evidence).
- 2.We suggest that, if possible, in patients scheduled for CABG, clopidogrel and ticagrelor be discontinued for 5 days and prasugrel for 7 days before surgery (Conditional Recommendation, Low-Quality Evidence).
- 3.We recommend that DAPT be continued for 12 months in patients with ACS after CABG (Strong Recommendation, Moderate-Quality Evidence).

Should Novel Oral Anticoagulants Be Used With Antiplatelet Agents for Secondary Prevention After ACS?
- Wright R.S.
- Anderson J.L.
- Adams C.D.
- et al.
Should PPIs Be Used in Patients Taking DAPT That Includes Clopidogrel?
- Wiviott S.D.
- Trenk D.
- Frelinger A.L.
- et al.
- Simon T.
- Steg P.G.
- Gilard M.
- et al.
- Harjai K.J.
- Shenoy C.
- Orshaw P.
- Usmani S.
- Boura J.
- Mehta R.H.
- Simon T.
- Steg P.G.
- Gilard M.
- et al.
- Harjai K.J.
- Shenoy C.
- Orshaw P.
- Usmani S.
- Boura J.
- Mehta R.H.
- Simon T.
- Steg P.G.
- Gilard M.
- et al.
- Harjai K.J.
- Shenoy C.
- Orshaw P.
- Usmani S.
- Boura J.
- Mehta R.H.
Acknowledgements
Funding Sources
References
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Footnotes
The disclosure information of the authors and reviewers is available from the CCS on the following websites: www.ccs.ca and/or www.ccsguidelineprograms.ca.
This statement was developed following a thorough consideration of medical literature and the best available evidence and clinical experience. It represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific recommendations. These recommendations are aimed to provide a reasonable and practical approach to care for specialists and allied health professionals obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scientific knowledge and technology advance and as practice patterns evolve. The statement is not intended to be a substitute for physicians using their individual judgement in managing clinical care in consultation with the patient, with appropriate regard to all the individual circumstances of the patient, diagnostic and treatment options available and available resources. Adherence to these recommendations will not necessarily produce successful outcomes in every case.