Guidelines for antiplatelet therapy in the secondary prevention of ACS,
indicating year of latest update
Date of
publication
ACCP
ESC
ACC/AHA
2012242
2011221
2014545
UA/NSTEMI
No stent
Bare-metal stent
ASA 150–300 mg loading dose
then 75–100 mg daily continued
ASA 75–100 mg daily
long term, PLUS a P2Y12
Ticagrelor 90 mg twice inhibitor for 12 months; one of:
•
Ticagrelor 180 mg loading
daily or clopidogrel
75 mg daily Recomdose then 90 mg twice
dailya
mended for 12 months
After 12 months: ASA
•
Prasugrel 60 mg loading
75–100 mg daily or
dose then 10 mg dailyb,c
clopidogrel 75 mg daily •
Clopidogrel 300 mg loading
dose then 75 mg dailyd
ASA 75–100 mg daily
Ticagrelor 90 mg twice
daily, clopidogrel 75
mg daily or prasugrel
10 mg daily RecomAs above
mended for 12 months,
minimum 1 month
After 12 months: ASA
75–100 mg daily or
clopidogrel 75 mg daily
ASA 162–325 mg promptly after
presentation then a maintenance
dose of ASA 81–162 mg daily
continued indefinitely, PLUS
a P2Y12 inhibitor for up to 12
months; one of:
•
Clopidogrel 300 or 600 mg
loading dose then 75 mg
daily
•
Ticagrelor 180 mg loading
dose then 90 mg twice dailye
ASA 162–325 mg promptly after
presentation then a maintenance
dose of 81–325 mg daily continued indefinitely,f PLUS a P2Y12
inhibitor for at least 12 monthsf
or beyond; one of:
•
•
•
Clopidogrel 300 or 600 mg
loading dose then 75 mg
daily
Prasugrel 60 mg loading
dose then 10 mg dailyc
Ticagrelor 180 mg loading
dose then 90 mg twice dailye
Drug-eluting stent
ASA 75–100 mg daily
Ticagrelor 90 mg
twice daily, clopidogrel
75 mg daily or
prasugrel 10 mg daily
Recommended for
12 months, minimum
3–6 months After 12
months: ASA 75–100
mg daily or clopidogrel
75 mg daily
As above
As for bare-metal stent
Date of
publication
2012242
2012222
2013546
STEMI
For patients who did not
receive reperfusion therapy:
ASA 150–500 mg loading
dose, then 75–100 mg daily
indefinitely, PLUS clopidogrel
75 mg daily for at least 1 month
and up to 12 months
For patients who underwent
fibrinolysis:
ASA 150–500 mg loading
dose, then 75–100 mg daily
indefinitely, PLUS clopidogrel
loading dose of 300 mg then 75
mg daily for up to 12 months
No stent
As for UA/NSTEMI
For patients who underwent
PCI without stent placement:i
ASA 150–500 mg loading
dose, then 75–100 mg daily
indefinitely, PLUS a P2Y12
inhibitor for up to 12 months;
one of:
•
•
•
Clopidogrel 600 mg loading
dose then 75 mg daily
Prasugrel 60 mg loading
dose then 10 mg dailyc,j,k
Ticagrelor 180 mg loading
dose then 90 mg twice daily
For patients who underwent
fibrinolysis:
ASA 162–325 mg loading
dose then maintenance dose
of 81–325 mg daily continued
indefinitely,f PLUS clopidogrel
loading dose of 300 mgh then 75
mg daily for at least 14 days and
up to 12 months
For patients who underwent
PCI without stent placement –
recommendations as for those
listed for Bare-metal stent
For selected patients who
receive ASA and clopidogrel:
Low-dose rivaroxaban (2.5 mg
twice daily) may be considered
if the patient is at low risk of
bleeding
Bare-metal stent
Drug-eluting stent
As for UA/NSTEMI
As for UA/NSTEMI
As recommended for patients
who underwent PCI without
stent placement – dual
antiplatelet therapy with ASA
plus a P2Y12 inhibitor must be
continued for up to 12 months
with a strict minimum of 1
month
As recommended for patients
who underwent PCI without
stent placement – dual
antiplatelet therapy with ASA
plus a P2Y12 inhibitor must be
continued for up to 12 months
with a strict minimum of 6
months
ASA 162–325 mg loading
dose then 81–325 mg daily
indefinitely,f PLUS a P2Y12
inhibitor for 12 months; one of:
•
•
•
Clopidogrel 600 mg loading
dose then 75 mg daily
Prasugrel 60 mg loading
dose then 10 mg dailyc
Ticagrelor 180 mg loading
dose then 90 mg twice dailye
As above, although treatment
with P2Y12 inhibitor may be
continued beyond 12 months
Ticagrelor is recommended for all patients at moderate-to-high risk of ischaemic events (e.g. elevated troponins), regardless of initial treatment strategy and including those pre-treated with clopidogrel (which should be discontinued when
ticagrelor is commenced); bprasugrel is recommended for P2Y12-inhibitor-naïve patients in whom coronary anatomy is
known and who are proceeding to PCI unless there is a high risk of life-threatening bleeding or other contraindications;
c
prasugrel is contraindicated in patients with a history of stroke or transient ischaemic attack; dclopidogrel is recommended
for patients who cannot receive ticagrelor or prasugrel; eif ticagrelor is given, the recommended maintenance dose of ASA
is 81 mg daily; fthe preferred maintenance dose of ASA is 81 mg daily; gif the risk of morbidity from bleeding outweighs the
anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation
(e.g. <12 months) of P2Y12 inhibitor therapy is reasonable; ha 300 mg loading dose for patients ≤75 years of age only; for
patients >75 years old a 75 mg dose should be given; ifor patients who underwent PCI dual antiplatelet therapy with ASA
and prasugrel or ASA and ticagrelor is recommended over ASA and clopidogrel; jin patients with a body weight of <60 kg,
a 5 mg daily maintenance dose of prasugrel is recommended; kprasugrel is not generally recommended in patients ≥75
years old, but a maintenance dose of 5 mg daily should be used if treatment is deemed necessary;
a
ACC, American College of Cardiology; ACCP, American College of Chest Physicians; AHA, American Heart Association;
ASA, acetylsalicylic acid; ESC, European Society of Cardiology; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction; UA, unstable angina.