Skip to main content
SpringerLink
Log in

Antiplatelet Agents in Ischemic Heart Disease

  • Chapter
  • First Online:
Antiplatelet Agents

Part of the book series: Handbook of Experimental Pharmacology ((HEP,volume 210))

Abstract

Antiplatelet agents comprise a critical component in the multi-modality treatment of ischemic heart disease. In addition to anticholesterol, beta-blocking, and angiotensin-converting enzyme inhibiting agents as well as mechanical intervention, platelet inhibition has resulted in improved outcomes for patients with ischemic heart disease. Platelet aggregation and resultant thrombus formation is a multi-step process with several points of potential intervention. As this pathway has been elucidated, more opportunities to intervene pharmacologically have become apparent.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 259.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 329.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 329.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  • Anderson KM et al (2001) Long-term mortality benefit with abciximab in patients undergoing percutaneous coronary intervention. J Am Coll Cardiol 37:2059–2065

    Article  PubMed  CAS  Google Scholar 

  • Anonymous (1988) 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 332:349–360

    Google Scholar 

  • Anonymous (1994) Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. The EPIC investigation. N Engl J Med 330:956–961

    Google Scholar 

  • Anonymous (1998) Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med 338:1488–1497

    Google Scholar 

  • Anonymous (1998) A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) Study Investigators. N Engl J Med 338:1498–1505

    Google Scholar 

  • Anonymous (1998) International, randomized, controlled trial of lamifiban (a platelet glycoprotein IIb/IIIa inhibitor), heparin, or both in unstable angina. The PARAGON Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute coronary syndrome events in a Global Organization Network. Circulation 97:2386–2395

    Google Scholar 

  • Anonymous (1998) Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med 339:436–443

    Google Scholar 

  • Antithrombotic Trialists’ Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324:71–86

    Article  Google Scholar 

  • Antoniucci D et al (2003) A randomized trial comparing primary infarct artery stenting with or without abciximab in acute myocardial infarction. J Am Coll Cardiol 42:1879–1885

    Article  PubMed  CAS  Google Scholar 

  • Bassand JP et al (2007) Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology. Eur Heart J 28:1598–1660

    Article  PubMed  CAS  Google Scholar 

  • Bernlochner I, Sibbing D (2012) Thienopyridines and other ADP-receptor antagonists. In: Gresele P, Born GVR, Patrono C, Page CP (eds) Antiplatelet agents. Springer, Heidelberg

    Google Scholar 

  • Bhatt DL et al (2006) Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 354:1706–1717

    Article  PubMed  CAS  Google Scholar 

  • Bhatt DL et al (2007) Patients with prior myocardial infarction, stoke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol 49:1982–1988

    Article  PubMed  Google Scholar 

  • Bhatt DL et al (2009) Intravenous platelet blockade with cangrelor during PCI. N Engl J Med 361:2330–2341

    Article  PubMed  CAS  Google Scholar 

  • Boersma E et al (2002) Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 359:189–198

    Article  PubMed  CAS  Google Scholar 

  • Brener SJ et al (1998) Randomized, placebo-controlled trial of platelet glycoprotein IIb/IIIa blockade with primary angioplasty for acute myocardial infarction. ReoPro and Primary PTCA Organization and Randomized Trial (RAPPORT) Investigators. Circulation 98:734–741

    Article  PubMed  CAS  Google Scholar 

  • Cairns JA et al (1985) Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. N Engl J Med 313:1369–1375

    Article  PubMed  CAS  Google Scholar 

  • Campbell C et al (2007) Aspirin dose for the prevention of cardiovascular disease: a systematic review. JAMA 297:2018–2024

    Article  PubMed  CAS  Google Scholar 

  • CAPRIE Steering Committee (1996) A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 348:1329–1339

    Article  Google Scholar 

  • Chen ZM et al (2005) Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 366:1607–1621

    Article  PubMed  CAS  Google Scholar 

  • Chew DP et al (2001) Increased mortality with oral platelet glycoprotein IIb/IIIa antagonists: a meta-analysis of the phase III multicenter randomized trials. Circulation 103:201–206

    Article  PubMed  CAS  Google Scholar 

  • Chin CT et al (2010) Study design and rationale of a comparison of prasugrel and clopidogrel in medically managed patients with unstable angina/non-ST-segment elevation myocardial infarction: the TaRgeted platelet Inhibition to cLarify the Optimal strateGy to medicallY manage Acute Coronary Syndromes (TRILOGY ACS) trial. Am Heart J 160:16–22

    Article  PubMed  CAS  Google Scholar 

  • Dangas G et al (2009) Role of clopidogrel loading dose in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: results from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol 54:1438–1446

    Article  PubMed  CAS  Google Scholar 

  • De Luca G et al (2005) Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA 293:1759–1765

    Article  PubMed  Google Scholar 

  • De Luca G et al (2009) Benefits from small molecule administration as compared with abciximab among patients with ST-segment elevation myocardial infarction treated with primary angioplasty: a meta-analysis. J Am Coll Cardiol 53:1668–1673

    Article  PubMed  Google Scholar 

  • EPILOG Investigators (1997) Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 336:1689–1696

    Article  Google Scholar 

  • EPISTENT Investigators (1998) Randomised placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of a platelet glycoprotein-IIb/IIIa blockade. Lancet 352:87–92

    Article  Google Scholar 

  • ESPRIT Investigators (2000) Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet 356:2037–2044

    Article  Google Scholar 

  • Giugliano RP et al (2009) Early versus delayed, provisional eptifibatide in acute coronary syndromes. N Engl J Med 360:2176–2190

    Article  PubMed  CAS  Google Scholar 

  • Global Organization Network (PARAGON)-B Investigators (2002) Randomized, placebo-controlled trial of titrated intravenous lamifiban for acute coronary syndromes. Circulation 105:316–321

    Article  Google Scholar 

  • Harrington RA et al (2009) Platelet inhibition with cangrelor in patients undergoing PCI. N Engl J Med 361:2318–2329

    Article  PubMed  CAS  Google Scholar 

  • Hook KM, Bennett JS (2012) Glycoprotein IIb/IIIa antagonists. In: Gresele P, Born GVR, Patrono C, Page CP (eds) Antiplatelet agents. Springer, Heidelberg

    Google Scholar 

  • ISIS-2 (Second International Study of Infarct Survival) Collaborative Group (1988) Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 332:349–360

    Article  Google Scholar 

  • Juul-Moller S et al (1992) Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet 340:1421–1425

    Article  PubMed  CAS  Google Scholar 

  • Kastrati A et al (2004) A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 350:232–238

    Article  PubMed  CAS  Google Scholar 

  • Kastrati A et al (2006) Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial. JAMA 295:1531–1538

    Article  PubMed  CAS  Google Scholar 

  • Lewis HD Jr et al (1983) Protective effects of aspirin against acute myocardial infarction and death in med with unstable angina. Results of a Veterans Administration Cooperative Study. N Engl J Med 309:396–403

    Article  PubMed  Google Scholar 

  • Lincoff AM et al (2003) Bivalirudin and provisional glycoprotein IIb/IIIa blockade compared with heparin and planned glycoprotein IIb/IIIa blockade during percutaneous coronary intervention: REPLACE-2 randomized trial. JAMA 289:853–863

    Article  PubMed  CAS  Google Scholar 

  • Mauri L et al (2010) Rationale and design of the dual antiplatelet therapy study, a prospective, multicenter, randomized, double-blind trial to assess the effectiveness and safety of 12 versus 30 months of dual antiplatelet therapy in subjects undergoing percutaneous coronary intervention with either drug-eluting stent or bare metal stent placement for the treatment of coronary artery lesions. Am Heart J 160:1035–1041

    Article  PubMed  CAS  Google Scholar 

  • Mehta SR et al (2001) Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 358:527–533

    Article  PubMed  CAS  Google Scholar 

  • Mehta SR et al (2010) Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med 363:930–942

    Article  PubMed  Google Scholar 

  • Montalescot G et al (2001) Platelet glycoprotein IIb/IIIa inhibition with coronary stenting for acute myocardial infarction. N Engl J Med 344:1895–1903

    Article  PubMed  CAS  Google Scholar 

  • Montalescot G et al (2006) A randomized comparison of high clopidogrel loading doses in patients with non-ST-segment elevation acute coronary syndromes: the ALBION (Assessment of the Best Loading Dose of Clopidogrel to Blunt Platelet Activation, Inflammation, and Ongoing Necrosis) trial. J Am Coll Cardiol 48:931–938

    Article  PubMed  CAS  Google Scholar 

  • Montalescot G et al (2007) Abciximab in primary coronary stenting of ST-elevation myocardial infarction: a European meta-analysis on individual patients’ data with long-term follow-up. Eur Heart J 28:443–449

    Article  PubMed  CAS  Google Scholar 

  • Montalescot G et al (2009) Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 373:723–731

    Article  PubMed  CAS  Google Scholar 

  • Neumann FJ et al (2000) Effect of glycoprotein IIb/IIIa receptor blockade with abciximab on clinical and angiographic restenosis rate after the placement of coronary stents following acute myocardial infarction. J Am Coll Cardiol 35:915–921

    Article  PubMed  CAS  Google Scholar 

  • Patrono C, Rocca B (2012) Aspirin and other COX-1 inhibitors. In: Gresele P, Born GVR, Patrono C, Page CP (eds) Antiplatelet agents. Springer, Heidelberg

    Google Scholar 

  • Patti G et al (2005) Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study. Circulation 111:2099–2106

    Article  PubMed  CAS  Google Scholar 

  • Sabatine MS et al (2005) Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 253:1179–1189

    Article  Google Scholar 

  • Schwartz MD et al (1988) Aspirin and dipyridamole in the prevention of re-stenosis after percutaneous transluminal coronary angioplasty. N Engl J Med 318:1714–1719

    Article  PubMed  CAS  Google Scholar 

  • Simoons ML et al (2001) Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial. Lancet 357:1915–1924

    Article  PubMed  CAS  Google Scholar 

  • Steinhubl SR et al (2002) Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 288:2411–2420

    Article  PubMed  CAS  Google Scholar 

  • Stone GW et al (2002) Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med 346:957–966

    Article  PubMed  CAS  Google Scholar 

  • Stone GW et al (2006) Bivalirudin for patients with acute coronary syndromes. N Engl J Med 355:2203–2216

    Article  PubMed  CAS  Google Scholar 

  • Stone GW et al (2007) Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial. JAMA 297:591–602

    Article  PubMed  CAS  Google Scholar 

  • Stone GW et al (2008) Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med 358:2218–2230

    Article  PubMed  CAS  Google Scholar 

  • Stone GW et al (2011) Heparin plus a glycoprotein IIb/IIIa inhibitor versus bivalirudin monotherapy and paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction (HORIZONS-AMI): final 3-year results from a multicentre, randomised controlled trial. Lancet 377:2193–2204

    Article  PubMed  CAS  Google Scholar 

  • The EPIC investigators (1994) Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 330:956–961

    Article  Google Scholar 

  • The PARAGON Investigators (1998) International, randomized, controlled trial of lamifiban (a platelet glycoprotein IIb/IIIa inhibitor), heparin, or both in unstable angina. Circulation 97:2386–2395

    Article  Google Scholar 

  • The Platelet Receptor Inhibition in Ischemic Syndrome Management (PRISM) Study Investigators (1998) A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med 338:1498–1505

    Article  Google Scholar 

  • The Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM- PLUS) Study Investigators (1998) Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. N Engl J Med 338:1488–1497

    Article  Google Scholar 

  • The PURSUIT Trial Investigators (1998) Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. N Engl J Med 339:436–443

    Article  Google Scholar 

  • The RISC Group (1990) Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease. Lancet 336:827–830

    Article  Google Scholar 

  • Theroux P et al (1988) Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med 319:1105–1111

    Article  PubMed  CAS  Google Scholar 

  • Topol EJ et al (2001) Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tirofiban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med 344:1888–1894

    Article  PubMed  CAS  Google Scholar 

  • Topol EJ et al (2003) Randomized, double-blind, placebo-controlled, international trial of the oral IIb/IIIa antagonist lotrafiban in coronary and cerebrovascular disease. Circulation 108:399–406

    Article  PubMed  CAS  Google Scholar 

  • von Beckerath N et al (2005) Absorption, metabolization, and antiplatelet effects of 300-, 600-, and 900-mg loading doses of clopidogrel: results of the ISAR-CHOICE (Intracoronary Stenting and Antithrombotic Regimen: Choose Between 3 High Oral Doses for Immediate Clopidogrel Effect) Trial. Circulation 112:2946–2950

    Google Scholar 

  • Wallentin L et al (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 361:1045–1057

    Article  PubMed  CAS  Google Scholar 

  • Wiviott SD et al (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357:2001–2015

    Article  PubMed  CAS  Google Scholar 

  • Yusuf S et al (2001) Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 345:494–502

    Article  PubMed  CAS  Google Scholar 

  • Zeymer U et al (2010) Randomized comparison of eptifibatide versus abciximab in primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: results of the EVA-AMI Trial. J Am Coll Cardiol 56:463–469

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiovascular Medicine, Cleveland Clinic, The Cleveland Clinic Foundation, 9500 Euclid Avenue – J2-3, Cleveland, OH, 44195, USA

    Christopher H. May & A. Michael Lincoff

Authors
  1. Christopher H. May
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. A. Michael Lincoff
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. Michael Lincoff .

Editor information

Editors and Affiliations

  1. , Department of Internal Medicine, University of Perugia, Via E. dal Pozzo, Perugia, 06126, Italy

    Paolo Gresele

  2. Institute, The William Harvey Research, Charterhouse Square, London, EC1M6BQ, United Kingdom

    Gustav V. R Born

  3. Istituto di Farmacologia, Università Cattolica del S. Cuore, Largo F. Vito 1, Roma, 00168, Italy

    Carlo Patrono

  4. King's College London, Sackler Inst. Pulmonary Pharmacology, Waterloo Campus, London, SE1 9NH, United Kingdom

    Clive P. Page

Appendix

Appendix

Recommended antiplatelet therapy for chronic ischemic heart disease

 

Secondary prevention

Prior to elective PCI

Aspirin

75–81 mg daily indefinitelya

300–325 mg loading dose for those not on aspirin (or on lower daily dose), then

  162–325 mg daily for 1 month for BMSb

  162–325 mg daily for 3 months for SES7b

  162–325 mg daily for 6 months for PESb, followed by

75–162 mg daily indefinitely

Clopidogrel

75 mg daily indefinitely in patients intolerant to aspirin

75 mg daily combined with aspirin up to 1 year after hospitalization for ACS

600 mg loading dose at least 2 h (preferably 24 h) prior to PCI, then

  75 mg daily for at least 1 month for BMS

  75 mg daily 1 year for DES

GP IIb/IIIa inhibitors

None

Use is generally limited to patients with higher risk, those who have not received pretreatment with clopidogrel, or those with a higher risk angiographic resultc

  1. aMay also consider this dose in patients with known coronary artery disease but no history of myocardial infarction
  2. bConsider lower dose of 75–162 mg daily in patients at high risk of bleeding
  3. cAlternatives to GP IIb/IIIa inhibitor include heparin (when pretreated with clopidogrel) or bivalirudin (pretreated or not pretreated with clopidogrel)
  4. BMS bare metal stent, SES sirolimus-eluting stent, PES paclitaxel eluting stent, DES drug-eluting stent

Recommended antiplatelet therapy for unstable angina and non-ST segment elevation myocardial infarction

 

Conservative strategy

Invasive strategy

Aspirin

162–325 mg loading dose, followed by

75–162 mg daily indefinitely

162–325 mg loading dose, followed by

  162–325 mg daily for 1 month for BMSa

  162–325 mg daily for 3 months for SESa

  162–325 mg daily for 6 months for PESa, followed by

75–162 mg daily indefinitely

ADP inhibitors

Clopidogrel

300 mg loading dose followed by 75 mg daily for at least 1 month, ideally for 1 year

Prasugrel

Not currently recommended, under investigation

Ticagrelor

180 mg loading dose, followed by 90 mg twice daily for at least 1 yeard

Clopidogrel

600 mg loading dose, followed by 75 mg for at least 1 month for BMS (ideally 1 year) or 75 mg 1 year for DESb, OR

Prasugrel (if patient is undergoing PCI)c

60 mg loading dose, followed by 10 mg daily for at least 1 year, OR

Ticagrelor

180 mg loading dose, followed by 90 mg twice daily for at least 1 yeard

GP IIb/IIIa inhibitors

Eptifibatide or tirofiban use is reserved for refractory symptoms or in patients not receiving an ADP inhibitor. Abciximab use is not recommended

Eptifibatide: 180 mcg/kg IV bolus, followed by 2 mcg/kg/min; reduce to 1 mcg/kg/min if CrCl < 50 mL/min

Tirofiban: 25 mcg/kg IV bolus, then 0.15 mcg/kg/min; reduce by 50 % if CrCl < 30 mL/min

Upstream

At time of PCI

Eptifibatide or Tirofiban for patients who did not receive ADP inhibitor prior to PCI

Consider GP IIb/IIIa inhibitor, in addition to aspirin and ADP inhibitor, in high risk patients (elevated troponin levels, diabetes, or significant ST-segment depression)

GP IIb/IIIa inhibitors (abciximab, eptifibatide, or tirofiban) can be administered to patients with higher risk angiographic features or in patients with thrombotic complications

  Abciximab: 0.25 mg/kg IV bolus, then 0.125 mcg/kg/min up to 12 h

  Eptifibatide: 180 mcg/kg IV bolus followed by second 180 mcg/kg IV bolus after 10 min. 2.0 mcg/kg/min should be started after the first bolus; reduce rate by 50 % in patients with CrCl < 50 mL/min. Continue for 12–18 h

  Tirofiban: 25 mcg/kg IV bolus, then 0.1 mcg/kg/min; reduce rate by 50 % in patients with CrCl < 30 mL/min. Continue for 18 h

GP IIb/IIIa inhibition may be omitted if bivalirudin is used as the anticoagulant and at least 300 mg of clopidogrel was given more than 6 h prior to PCI

  1. aConsider lower dose of 75–162 mg daily in patients at high risk of bleeding
  2. bIn patients with a low risk of bleeding, an alternative regimen consisting of a 600 mg loading dose, then 150 mg daily for 6 days, followed by 75 mg for at least 1 month for BMS (ideally 1 year) or 75 mg 1 year for DES may be better
  3. cContraindicated in patients with history of TIA or stroke. Avoid in patients age >75 and dose adjust in patients <60 kg
  4. dWhen ticagrelor is prescribed, a low aspirin dose of 75–100 mg daily should be used
  5. BMS bare metal stent, SES sirolimus-eluting stent, PES paclitaxel eluting stent, DES drug-eluting stent

Recommended antiplatelet therapy for ST-segment myocardial infarction

 

Receiving fibrinolysis

Undergoing primary PCI

Aspirin

162–325 mg loading dose, followed by

  162–325 mg daily for 1 month for BMSa

  162–325 mg daily for 3 months for SESa

  162–325 mg daily for 6 months for PESa, followed by

75–162 mg daily indefinitely

162–325 mg loading dose, followed by

  162–325 mg daily for 1 month for BMSa

  162–325 mg daily for 3 months for SESa

  162–325 mg daily for 6 months for PESa, followed by

75–162 mg daily indefinitely

ADP inhibitors

Clopidogrel

Age <75: 300 mg loading dose followed by 75 mg daily for at least 14 days, ideally for 1 year.

Age ≥75: 75 mg daily with no loading dose for at least 14 days, ideally for 1 year

Prasugrel

Not recommended; has not been studied

Ticagrelor

Not recommended; has not been studied

Clopidogrel

600 mg loading dose, followed by 75 mg for at least 1 month for BMS (ideally 1 year) or 75 mg 1 year for DESb, OR

Prasugrel c

60 mg loading dose, followed by 10 mg daily for at least 1 year , OR

Ticagrelor

180 mg loading dose, followed by 90 mg twice daily for at least 1 yeard

GP IIb/IIIa inhibitors

Of uncertain benefit

At time of PCI with heparin used as the anticoagulant, either:

Abciximab: 0.25 mg/kg IV bolus, followed by 0.125 mcg/kg/min up to 12 h

Eptifibatide: 180 mcg/kg IV bolus followed by another 180mcg/kg IV bolus after 10 min. 2.0 mcg/kg/min should be started after the first bolus; reduce rate by 50 % in patients with CrCl < 50 mL/min. Continue for 12–18 h

Tirofiban: 25 mcg/kg IV bolus followed by 0.1 mcg/kg/min; reduce rate by 50 % in patients with CrCl < 30 mL/min. Continue for 18 h

If bivalirudin is used as the anticoagulant, GP IIb/IIIa inhibitors can be used provisionally for ischemic complications, angiographic complications, or high-risk features

  1. aConsider lower dose of 75–162 mg daily in patients at high risk of bleeding
  2. bIn patients with a low risk of bleeding, an alternative regimen consisting of a 600 mg loading dose, then 150 mg daily for six days, followed by 75 mg for at least 1 month for BMS (ideally 1 year) or 75 mg 1 year for DES may be better
  3. cPreferred therapy over clopidogrel. Contraindicated in patients with history of TIA or stroke. Avoid in patients age >75 and dose adjust in patients <60 kg
  4. dWhen ticagrelor is prescribed, a low aspirin dose of 75–100 mg daily should be used
  5. BMS bare metal stent, SES sirolimus-eluting stent, PES paclitaxel eluting stent, DES drug-eluting stent

Rights and permissions

Reprints and permissions

Copyright information

© 2012 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

May, C.H., Lincoff, A.M. (2012). Antiplatelet Agents in Ischemic Heart Disease. In: Gresele, P., Born, G., Patrono, C., Page, C. (eds) Antiplatelet Agents. Handbook of Experimental Pharmacology, vol 210. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-29423-5_20

Download citation

Publish with us

Policies and ethics

Search

Navigation