Dual antiplatelet therapy for percutaneous coronary intervention

For patients with a STEMI undergoing primary percutaneous coronary intervention (PCI) or in whom PCI is planned, give aspirin plus a P2Y12 inhibitor; use:

aspirin 300 mg orally, chewed or dissolved before swallowing, for the first dose, then 100 to 150 mg daily1 aspirin aspirin aspirin

PLUS ONE OF THE FOLLOWING

1prasugrel 60 mg orally, for the first dose, then 10 mg daily23 prasugrel prasugrel prasugrel

OR

1ticagrelor 180 mg orally, for the first dose, then 90 mg twice daily ticagrelor ticagrelor ticagrelor

OR

2clopidogrel 600 mg orally, for the first dose, then 75 mg daily. clopidogrel clopidogrel clopidogrel

The preferred P2Y12 inhibitors for a patient undergoing PCI are ticagrelor and prasugrel; these have more rapid onset of action, less variable platelet inhibition, and better clinical outcomes than clopidogrelCollet, 2021Wallentin, 2009Wiviott, 2007.

Clopidogrel is used if ticagrelor and prasugrel are not available or are contraindicated4, including if the patient:

  • is being treated with thrombolytic therapy
  • 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, recent gastrointestinal bleeding or anaemia, or has a coagulopathy
  • has liver failure, or severe kidney failure (estimated glomerular filtration rate [eGFR] less than 15 mL/min or requiring dialysis)
  • is of extreme old age or frail.

See Antithrombotic therapy after insertion of a coronary artery stent for long-term management of antithrombotic therapy for patients with a stent.

1 If the patient has already received a 300 mg dose of aspirin as initial therapy for acute chest pain of possible cardiac origin, do not repeat this initial 300 mg dose.Return
2 Do not use prasugrel for patients who weigh less than 60 kg, are aged 75 years or older, or who have had a previous stroke or transient ischaemic attack. Only give prasugrel once coronary anatomy has been defined and PCI is intended.Return
3 At the time of writing, prasugrel is not available on the Pharmaceutical Benefits Scheme (PBS). See the PBS website for current information.Return
4 Do not use prasugrel for patients who weigh less than 60 kg, are aged 75 years or older, or who have had a previous stroke or transient ischaemic attack. Only give prasugrel once coronary anatomy has been defined and PCI is intended. Do not use ticagrelor for patients who have second- or third-degree atrioventricular (AV) block.Return