NSTE-ACS: Definite or likely

Ischemia-guided strategy

Early invasive strategy

Initiate DAPT and anticoagulant therapy

ASA (class I; LOE: A)
P2Y₁₂ inhibitor (in addition to ASA) (class I; LOE: B):


Clopidogrel or
Ticagrelor


Anticoagulant:


UFH (classI; LOE: B) or
Enoxaparin (class I; LOE: A) or
Fondaparinux^† (class I; LOE: B) or
Bivalirudin (class I; LOE: B)

Clopidogrel or
Ticagrelor

UFH (classI; LOE: B) or
Enoxaparin (class I; LOE: A) or
Fondaparinux^† (class I; LOE: B) or
Bivalirudin (class I; LOE: B)

Initiate DAPT and anticoagulant therapy

ASA (class I; LOE: A)
P2Y₁₂ inhibitor (in addition to ASA) (class I; LOE: B):


Clopidogrel or
Ticagrelor


Anticoagulant:


UFH (class I; LOE: B) or
Enoxaparin (class I; LOE: A) or
Fondaparinux† (class I; LOE: B)

Clopidogrel or
Ticagrelor

UFH (class I; LOE: B) or
Enoxaparin (class I; LOE: A) or
Fondaparinux† (class I; LOE: B)

Late hospital/posthospital care

ASA indefinitely (class I; LOE: A)
P2Y₁₂ inhibitor (clopidogrel or ticagrelor), in addition to ASA, up to 12 mo of medically treated (class I; LOE: B)
P2Y₁₂ inhibitor (clopidogrel, prasugrel, or ticagrelor), in addition to ASA, at least 12 mo if treated with coronary stenting (class I; LOE: B)

Therapy effective

Therapy ineffective

End

^†In patients who have been treated with fondaparinux (as upfront therapy) who undergo percutaneous coronary intervention (PCI), an additional anticoagulant with anti-IIa activity should be administered at the time of PCI because of the risk of catheter thrombosis.

PCI with stenting initiate/continue antiplatelet and anticoagulant therapy

ASA (class I; LOE: B)
P2Y₁₂ inhibitor (in addition to ASA): (class I; LOE: B):


Clopidogrel (class I; LOE: B) or
Prasugrel (class I; LOE: B) or
Ticagrelor (class I; LOE: B)


GPI (if not treated with bivalirudin at time of PCI)


High-risk features, not adequately pretreated with clopidogrel (class I; LOE: A)
High-risk features, adequately pretreated with clopidogrel (class IIa; LOE: B)


Anticoagulant:

Clopidogrel (class I; LOE: B) or
Prasugrel (class I; LOE: B) or
Ticagrelor (class I; LOE: B)

High-risk features, not adequately pretreated with clopidogrel (class I; LOE: A)
High-risk features, adequately pretreated with clopidogrel (class IIa; LOE: B)

Enoxaparin (class I; LOE: A) or
Bivalirudin (class I; LOE: B) or
Fondaparinux^† as the sole anticoagulant (class III: Harm; LOE: B) or
UFH (class I; LOE: B)

Enoxaparin (class I; LOE: A) or
Bivalirudin (class I; LOE: B) or
Fondaparinux^† as the sole anticoagulant (class III: Harm; LOE: B) or
UFH (class I; LOE: B)

CABG initiate/continue ASA therapy and discontinue P2Y₁₂ and/ or GPI therapy

ASA (class I; LOE: A)
Discontinue clopidogrel/ticagrelor 5 days before, and prasugrel at least 7 days before elective CABG
Discontinue clopidogrel/ticagrelor up to 24 hr before urgent CABG (class I; LOE: B). May perform urgent CABG <5 days after clopidogrel/ticagrelor and <7 days after prasugrel discontinued
Discontinue eptifibatide/tirofiban at least 2-4 hr before, and abciximab ≥12 hr before CABG (class I; LOE: B)

Can consider GPI in addition to ASA and P2Y12 inhibitor in high-risk (e.g., troponin positive) pts (class IIb; LOE: B)

Eptifibatide
Tirofiban

Medical therapy chosen based on catheter findings

CABG initiate/continue ASA therapy and discontinue P2Y₁₂ and/ or GPI therapy

ASA (class I; LOE: A)
Discontinue clopidogrel/ticagrelor 5 days before, and prasugrel at least 7 days before elective CABG
Discontinue clopidogrel/ticagrelor up to 24 hr before urgent CABG (class I; LOE: B). May perform urgent CABG <5 days after clopidogrel/ticagrelor and <7 days after prasugrel discontinued
Discontinue eptifibatide/tirofiban at least 2-4 hr before, and abciximab ≥12 hr before CABG (class I; LOE: B)