Antiplatelet Agents in UA/NSTEMI
| Medication | Dosage | Comments |
|---|
| Aspirin (ASA) | 162–325 mg initial, then 75–100 mg daily | In patients taking ticagrelor, the maintenance dose of ASA should not exceed 100 mg. | | Clopidogrel | 300–600 mg loading dose, 75 mg daily | In combination with ASA, clopidogrel (300–600 mg loading dose, then 75 mg/d) decreased the composite end point of cardiovascular death, MI, or stroke by 18%–30% in patients with UA/NSTEMI.39, 40, 41 | | Ticagrelor | 180 mg loading dose, then 90 mg bid | Ticagrelor reduced incidence of vascular death, MI, or CVA (9.8% vs. 11.0%) but with higher major bleeding not related to CABG (4.5% vs. 3.8%) as compared to clopidogrel.42,43 | | Prasugrel | 60 mg loading dose, then 10 mg daily | Prasugrel has increased antiplatelet potency compared to clopidogrel.
Prasugrel reduced the incidence of cardiovascular death, MI, and stroke (9.9% vs. 12.1%) at the expense of increased major (2.4% vs. 1.1%) and fatal bleeding (0.4% vs. 0.1%), compared to clopidogrel.44 | | Cangrelor | 30 µg/kg IV bolus, then 4 µg/kg/min | Currently FDA approved only for patients undergoing PCI. Expense and modest evidence of benefit compared to other P2Y12 inhibitors limit use. | | Eptifibatide | 180 µg/kg IV bolus, then 2 µg/kg/mina | Eptifibatide reduces the risk of death or MI in patients with ACS undergoing either invasive or noninvasive therapy in combination with ASA and heparin.45,46
Compared to abciximab and tirofiban, eptifibatide has the most consistent effects on platelet inhibition with shortest on-time and drug half-life.47 | | Tirofiban | 0.4 µg/kg IV bolus, then 0.1 µg/kg/mina | Tirofiban reduces the risk of death or MI in patients with ACS undergoing either invasive or noninvasive therapy in combination with ASA and heparin.48, 49, 50 | | Abciximab | 0.25 mg/kg IV bolus, then 10 µg/minb | Abciximab reduces the risk of death or MI in patients with ACS undergoing coronary intervention.51, 52, 53 It should not be used in patients in whom percutaneous intervention is not planned.54
Platelet inhibition may be reversed by platelet transfusion. |
|
ACS, acute coronary syndrome; CABG, coronary artery bypass grafting; CVA, cerebrovascular accident; ESRD, end-stage renal disease; GFR, glomerular filtration rate; HD, hemodialysis; MI, myocardial infarction; NSTEMI, non–ST-segment elevation myocardial infarction; UA, unstable angina.
a Infusion doses should be decreased by 50% in patients with a GFR < 30 mL/min and avoided in patients on HD.
b Abciximab may be used in patients with ESRD because it is not cleared by the kidney.