Information ⬇
- Aspirin (325 mg initially, then 75-100 mg/d).
- Platelet P2Y12 receptor antagonist (unless excessive risk of bleeding or immediate coronary artery bypass grafting [CABG] likely): Clopidogrel (300-600 mg PO load, then 75 mg/d), ticagrelor (180 mg PO, then 90 mg PO bid [chronic aspirin dose should not exceed 100 mg daily]) or prasugrel (60 mg PO, then 10 mg daily—use prasugrel only if PCI is planned).
- Anticoagulant: Unfractionated heparin (UFH) [70-100 U/kg (maximum 5000 U) then 12 (U/kg)/h (maximum 1000 U/h)] to achieve aPTT 1.5-2.5 × control, or low-molecular-weight heparin (e.g., enoxaparin 1 mg/kg SC q12h), which is superior to UFH in reduction of future cardiac events. Alternatives include (1) the factor Xa inhibitor fondaparinux (2.5 mg SC daily), which is associated with lower bleeding risk, or (2) the direct thrombin inhibitor bivalirudin [0.75-mg/kg bolus, then 1.75 (mg/kg)/h], which causes less bleeding in pts undergoing catheterization compared with UFH plus a GP IIb/IIIa inhibitor.
- For high-risk unstable pts who undergo PCI, consider an IV GP IIb/IIIa antagonist [e.g., tirofiban, 25 (µg/kg)/min load, then 0.15 (µg/kg)/min for up to 18 h; or eptifibatide, 180-µg/kg bolus, then 2.0 (µg/kg)/min for 72-96 h].
Outline ⬆