title: Immediate and Long-Term Therapy of Patients with Acute Coronary Syndromes with Thienopyridines. Current Status According to the Latest European Society of Cardiology (ESC) Guidelines.
abstract: For patients with acute coronary syndrome (ACS), the first priority is to alert emergency services. In addition to an ECG (ideally taken during the first medical contact at the patient's home), the key of life saving is the immediate antithrombotic therapy with acetylsalicylic acid (ASA) and (unless contraindicated) an injection of unfractionated heparin or bivalirudin as an alternative anticoagulant. Dual anti-platelet therapy (ASA combined with other antiplatelet drugs, like thienopyridines) should be started as soon as possible in the ambulance or at the latest in the hospital. For clopidogrel, a loading dose of 600 mg is the standard. To avoid the risk of an unknown low or missing clopidogrel response, prasugrel is recommended instead, with administration of a loading dose of 60 mg, if no contraindication (s/p stroke or TIA) exists. When PCI is planned, the ambulance must head directly to the nearest hospital with continuous (24/7) PCI service within 90 (to 120) minutes. The maintenance dose for clopidogrel is 75 mg/d; a daily double-dose has not proven to be superior, even in "low responders". For prasugrel, the maintenance dose is usually 10 mg/d. To avoid bleeding complications in patients ≥ 75 y and/or < 60 kg, a prasugrel maintenance dose of 5 mg/d is recommended. The ESC guidelines recommend DAPT for 1 year after ACS in all patients - independent of the type of ACS and independent of whether any or which coronary stent has been implanted. With DAPT, the patient - and not the stent - is treated.
authors.affiliation: Heart Center at the Isar, Munich, Germany.
authors.forename: Sigmund
authors.initials: S
authors.lastname: Silber
keywords: Acute coronary syndrome; clopidogrel; myocardial infarction; percutaneous coronary intervention; prasugrel; stent
references.citation: Lancet. 2009 Feb 28;373(9665):723-31
references.pmid: 19249633
references.citation: J Am Coll Cardiol. 2009 Mar 10;53(10):849-56
references.pmid: 19264241
references.citation: N Engl J Med. 2010 Nov 11;363(20):1909-17
references.pmid: 20925534
references.citation: J Am Coll Cardiol. 2011 May 10;57(19):1920-59
references.pmid: 21450428
references.citation: N Engl J Med. 2007 Nov 15;357(20):2001-15
references.pmid: 17982182
references.citation: Am J Cardiol. 2010 May 1;105(9):1356-7
references.pmid: 20403493
references.citation: Circulation. 2008 Oct 14;118(16):1626-36
references.pmid: 18757948
references.citation: Eur Heart J. 2010 Apr;31(8):943-57
references.pmid: 19933242
references.citation: Lancet. 2010 Oct 16;376(9749):1312-9
references.pmid: 20801494
references.citation: Lancet. 2010 Oct 9;376(9748):1233-43
references.pmid: 20817281
references.citation: J Am Coll Cardiol. 2008 May 20;51(20):1925-34
references.pmid: 18482659
references.citation: N Engl J Med. 2009 Jan 22;360(4):354-62
references.pmid: 19106084
references.citation: Circulation. 2010 Jul 27;122(4):394-403
references.pmid: 20660815
references.citation: Circulation. 2010 Dec 14;122(24):2619-33
references.pmid: 21060077
references.citation: Circulation. 2007 Dec 18;116(25):2923-32
references.pmid: 18056526
references.citation: Lancet. 2008 Apr 19;371(9621):1353-63
references.pmid: 18377975
references.citation: Circulation. 2011 May 10;123(18):2022-60
references.pmid: 21444889
references.citation: Eur Heart J. 2010 Oct;31(20):2501-55
references.pmid: 20802248