Antiplatelet therapy for long-term management of acute coronary syndromes
Provided there are no contraindications to antiplatelet therapy, continue the dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor [ticagrelor, prasugrel, clopidogrel]) that was started in the acute stage of management of an acute coronary syndrome. Use:
aspirin 100 to 150 mg orally, daily aspirin aspirin aspirin
PLUS ONE OF THE FOLLOWING
1ticagrelor 90 mg orally, twice daily ticagrelor ticagrelor ticagrelor
OR
1prasugrel 10 mg orally, daily12 prasugrel prasugrel prasugrel
OR
2clopidogrel 75 mg orally, daily. clopidogrel clopidogrel clopidogrel
The preferred P2Y12 inhibitors are ticagrelor and prasugrel; these have more rapid onset of action, less variable platelet inhibition and better clinical outcomes than clopidogrelCollet, 2021Wallentin, 2009Wiviott, 2007. However, the greatest benefit over clopidogrel is seen within the first 3 months following an acute coronary event. For patients who develop adverse effects to ticagrelor or prasugrel, it may be reasonable to switch to clopidogrel.
Clopidogrel is preferred if ticagrelor and prasugrel are not available or are contraindicated3, including if the patient:
- has a separate indication for oral anticoagulation
- has a high or very high bleeding risk (eg a PRECISE-DAPT score of more than 25 or a HAS-BLED score of more than 3)
- has had prior intracranial haemorrhage or stroke, or recent gastrointestinal bleeding or anaemia, or has a coagulopathy
- has liver failure, or severe kidney failure (eGFR less than 15 mL/min or requiring dialysis)
- is of extreme old age or frailty.
For patients who have had a coronary stent inserted, see Antithrombotic therapy after insertion of a coronary artery stent for information about duration of dual antiplatelet therapy.
Dual antiplatelet therapy is usually recommended for 12 months after an acute coronary syndrome. Dual antiplatelet therapy for less than 12 months may be appropriate for selected patients (eg those at high risk of bleeding). Dual antiplatelet therapy for longer than 12 months may be appropriate for selected patients (eg those at high risk of recurrent ischaemic events). Any decision to vary the duration of dual antiplatelet therapy should be made under the direction of the patient’s cardiologist.
When stopping dual antiplatelet therapy, the P2Y12 inhibitor is usually stopped and aspirin is continued indefinitely either alone or in combination with low-intensity rivaroxaban therapy; see Drug therapy for secondary prevention of atherosclerotic cardiovascular events for more information. In select cases, or if aspirin is contraindicated, indefinite therapy with a P2Y12 inhibitor alone may be used.
A proton pump inhibitor is recommended in patients receiving dual antiplatelet therapy who are at high risk of gastrointestinal bleeding; see Proton pump inhibitors for more information.