ACLS review: Acute Coronary Syndromes Part 8

Clopidogrel

·         Oral thienopyridine that irreversibly inhibits the adenosine diphosphate receptor on the platelets, resulting in a reduction in platelet aggregation

·         AHA guidelines recommend withholding clopidogrel for 5 to 7 days in patients for whom CABG is anticipated

·         Patients <75 years of age a loading dose of clopidogrel 300 to 600 mg with non-STE ACS and STEMI followed  by maintenance dose of 75mg/day  is recommended

·         Give 300-mg of clopidogrel to ED patients with suspected ACS (without ECG or cardiac marker changes) who are unable to take aspirin

·         Little evidence on the use of a loading dose of clopidogrel in patients aged ≥75 years of age with NSTEMI and STEMI treated by PPCI

Prasugrel

·         An oral thienopyridine prodrug that irreversibly binds to the ADP receptor to inhibit platelet aggregation.

·         Small improvements in combined event when prasugrel (compared to clopidogrel) is administered before or after angiography to patients with NSTEMI and STEMI managed with PCI

·         An overall increase in major bleeding (as compared to clopidogrel) when administered after angiography to patients with NSTEMI undergoing PCI

·         Prasugrel (60 mg oral loading dose) may be substituted for clopidogrel after angiography in patients with non-ST-segment elevation ACS or STEMI who are more than 12 hours after symptom onset prior to planned PCI

·         Prasugrel is not recommended in STEMI patients managed with fibrinolysis or NSTEMI patients before angiography

Note:  Risk factors associated with a higher rate of bleeding with prasugrel use are age >75 years, previous stroke or TIA, and body weight less than 60 kg
Circulation. 2010; 122: S787-S817 doi: 10.1161/​CIRCULATIONAHA.110.971028

Statins

·         Reduction in indicators of inflammation and complications such as reinfarction, recurrent angina, and arrhythmias when statin treatment is administered within a few days after onset of an ACS

·         Early initiation (within 24 hours of presentation) of statin therapy is recommended in patients with an ACS or AMI

·         use statin pretreatment for patients who will be undergoing elective or urgent angioplasty in order to decrease perioperative myocardial infarction