Unstable angina non ST elevation myocardial infarction aspirin therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.

Overview of Antiplatelet Therapy in Unstable angina / NSTEMI

Antiplatelet therapy plays a major role in the management of Unstable angina/NSTEMI. This class of medication is directed towards one of the three pathways listed below:

Aspirin

Mechanism of benefit:

  • One of the medications which has consistently been shown to reduce mortality in ACS or CAD patients is ASA.

Clinical trial data: Until recently, no trial had directly compared the efficacy of different doses of ASA in patients who present with Unstable angina / NSTEMI.

  • CURRENT OASIS 7 trial, which was a randomized, multicenter, multinational trial enrolling 25,087 patients with ACS showed no difference in cardiovascular outcomes of death from MI or stroke between low dose aspirin(75-100mg) compared to high dose aspirin(300-325mg) at the end of 30 days.
  • The Second International Study of Infarct Survival (ISIS-2) trial[1] led to the recommendation that ASA be initiated immediately in the ED once the diagnosis of ACS is made or suspected. Aspirin therapy can also be initiated in prehospital setting when ACS is suspected.
  • For safety (e.g., gastrointestinal bleeding), a couple of large observational studies have found that the rate of bleeding appears to be lower with low-dose aspirin (75-100mg daily) as compared with high dose aspirin (325 mg daily) in patients receiving medical therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

Aspirin Dosing:

  • Non enteric coated formulations are preferred due to rapid buccal absorption.
  • On the basis of previous randomized trials, the current recommendation for initial dose of aspirin is 162-325mg.
  • After an initial loading dose of 162 to 325 mg, a dose of 75 to 100mg daily appears sufficient.
  • On the basis of current available data, lifelong continuation of aspirin should be encouraged unless a contraindication develops.
  • In patients who have an allergy or who cannot tolerate aspirin, use of clopidogrel is recommended.

ACC / AHA Guidelines for Antiplatelet therapy in Unstable Angina/NSTEMI (DO NOT EDIT) [2]

“

Class I

1. Aspirin should be administered to Unstable angina/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients who tolerate it. (Level of Evidence: A)


2. Patients with definite Unstable angina / NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual-antiplatelet therapy on presentation. (Level of Evidence: A) ASA should be initiated on presentation. (Level of Evidence: A) The choice of a second antiplatelet therapy to be added to ASA on presentation includes 1 of the following:

Before PCI:

At the time of PCI:


3. For Unstable angina / NSTEMI patients in whom an initial invasive strategy is selected, antiplatelet therapy in addition to aspirin should be initiated before diagnostic angiography (upstream) with either clopidogrel (loading dose followed by daily maintenance dose) or an intravenous GP IIb/IIIa inhibitor. (Level of Evidence: A) Abciximab as the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed; otherwise, IV eptifibatide or tirofiban is the preferred choice of GP IIb/IIIa inhibitor. (Level of Evidence: B)


4. A loading dose followed by daily maintenance dose of either clopidogrel (Level of Evidence: B), prasugrel (in PCI-treated patients) (Level of Evidence: C), or ticagrelor (Level of Evidence: C) should be administered to Unstable angina / NSTEMI patients who are unable to take aspirin because of hypersensitivity or major GI intolerance.

”

See Also

Sources

References

  1. ↑ "Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group". Lancet. 2 (8607): 349–60. 1988. PMID 2899772. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  2. ↑ 2.0 2.1 Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-30. Unknown parameter |month= ignored (help)
  3. ↑ Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-12. Unknown parameter |month= ignored (help)

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