aCAD Summary


    Based on Canadian Cardiology Society (CCS) Guidelines 2012

    and AHA NSTE-ACS Guidelines 2004 (2009 update)

    Post-ACS Anti-Platelet Therapies

    (For PCI, CABG, or Medical Therapy Alone)


    • ASA 81mg daily indefinitely in ALL patients (Strong, High)
    • Ticagrelor 90mg BID x12mo (in patients with moderate-to-high NSTEACS risk)
      • If anatomy defined, and PCI is planned: Prasugrel > clopidogrel (Strong, High)
        • AVOID Prasugrel in pts with prev. TIA, Stroke, or if not treated with PCI
        • AVOID Prasugrel before coronary anatomy is defined
        • AVOID Prasugrel in CABG
      • 2nd Line: clopidogrel
        • Use 150mg daily for first 6 days post-PCI (for ACS) (Strong, Moderate)
    • Switch patents from clopidogrel to others?
      • Only switch if had stent thrombosis (switch to ticagrelor or prasugrel), bleeding, CV event  [Strong, Low] 
    • DAPT beyond 12mo --> only if high risk of thrombosis and low bleeding risk







    • If Fibrinolytics OR Medically Managed:CADacs2.jpg
      • ASA + Clopidogrel 75mg daily for > 1mo [at least]
        • Suggest clopidogrel for at least 12mo [conditional, low]
    • If PCI reperfused:
      • ASA + (either Ticagrelor 90mg BID OR Prasugrel 10mg daily x12mo)
        • 2nd Line: ASA +  Clopidogrel 75mg daily x12mo (if not eligible for prasugrel/ticagrelor) [Strong, Moderate]
          • (Clopidogrel 150mg daily x first 6 days post-PCI)
        • NOTE: Prasugrel avoid if prev TIA/stroke (higher risk of intracranial bleed), reduce dose to 5mg in pts >75yo or ≤ 60kg











    Non-ACS Stented Patients

    • ASA + clopidogrel x1year
      • (AT LEAST 1mo of ASA/clopidogrel for Bare-Metal Stents)
      • (AT LEAST 3mo of ASA/clopidogrel for Drug-Eluting Stents if cannot manage 1yr)




    • STEMI
      • If thrombolysis or medical management --> Anticoagulate x48hrs (heparin/LMWH/fondaparinux)
      • If PCI --> Discuss with interventionalist (probably not), they can start heparin post-Cath based on anatomy
      • RECOMMENDED in addition to antiplatelet therapy regardless of treatment strategy
      • Enoxaparin 1mg/kg SC q12h (once daily if CrCl < 30 mL/min) continue while in hospital or until PCI performed
        • Loading dose of 30mg IV can be used in some patients. 
        • ESSENCE Trial (better than UFH), treated for 48h-8days.
      • Bivalirudin 0.10 mg/kg load + 0.25mg/kg/hr (only if early invasive - going for PCI, continue until PCI)
      • Fondaparinux: 2.5mg SC daily (continue while in hospital or until PCI performed)
        • IF PCI while on fonda --> add Anti-IIa activity (UFH or bivalirudin) due to risk of catheter thrombosis
      • UFH IV: Initial load of 60 IU/kg (max 4000 IU) + infuse @ 12 IU/kg/hr (max 1000 iu/hr) adjust to aPPT x48hrs or until PCI performed



    Before Surgery

    • Ideally (if pt stable)
      • Clopidogrel + Ticagrelor d/c 5d prior to OR
      • Prasugrel d/c 7d prior to OR
    • If Unstable --> Weigh risks/benefits of bleeding


    After Surgery

    • If ACS
      • DAPT for 12mo for ACS pts post-CABG [Strong, Moderate]
        • Prevents early graft occlusion (conflicting data) and CV events (clear data).
        • Clopidogrel, Prasugrel, and Ticagrelor demonstrate benefits post-CABG.
    • If Elective
      • Single Anti-platelet (usually ASA) post-CABG
    • Start DAPT within 48-72hrs post-OP (or as per CV surgery team)




    NOACs for ACS

    • Big push b/c platelets + coagulation factors involved in ACS
    • Not recommended (despite benefit) [Strong, High]
    • Rivaroxaban+Clopidogrel+ASA
      • Improves composite (CV death, MI, stroke, total mortality)
      • Increased risk of bleeding complications, and high cost
    • Practially "triple therapy" OAC + DAPT may be warranted (i.e. ACS + AFib or mechanical valve)
      • However, be careful with bleeding risk
    • Literature:
      • Apixaban + DAPT (ASA + plavix) did not reduce vascular events, but increased major fatal bleeds.
      • Dabigatran + DAPT increased risk of bleeding (not powered to assess vascular events)
      • Rivaroxaban (very low dose) + DAPT = significant vascular mortality benefit (increased ICH/fatal bleeds)


    Other Pearls

    PPI + Clopidogrel

    • SELETIVE use of PPI in patients with DAPT (only if high GI bleed risk)
      • CYP2C19 inhibition reduces effect of clopidogrel
    • Do not use routinely in all patients with DAPT, but only in those with high UGI bleed risk.
    • Avoid omeprazole and esomeprazole with clopidogrel (inhibit CYP2C19 --> decr. clopidogrel activity)
    • Panto is preferred


    ASA + NSAIDs

    • AVOID


    Stents in High-Bleeding patients

    •   Low Risk of Bleed High Risk of Bleed VERY HIGH RISK BLEED
      Bare Metal Stent 3mo of DAPT [Strong, High] 1mo of DAPT [Cond, Low] 2 weeks of DAPT [Cond, Low]
      Drug Eluting Stent 1yr of DAPT [Strong, High] 3mo of DAPT [Cond, Low]  
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