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Antiplatelets and Anticoagulants in NSTEMI Too Much Confusion: Which Ones should I Choose?

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Dr Smit Shrivastava, Kanpur    06 January 2018

  1. P2Y12 inhibitors for all patients. All NSTEACS patients should be treated with a P2Y receptor blocker and aspirin. Timing of administration depends on the choice between invasive or ischemia-guided management strategies. For invasive strategy: Ticagrelor 180 mg loading dose is recommended. For patients in whom there is a concern about a need for urgent CABG surgery, the P2Y receptor blocker may be given after diagnostic coronary angiography. If the P2Y receptor blocker is given after angiography, administer either ticagrelor 180 mg or prasugrel 60 mg. For ischemia-guided (conservative) strategy: Ticagrelor 180 mg loading dose is recommended.
  2. Most patients do not require IV glycoprotein IIb/IIIa inhibitor. Indications for IV glycoprotein IIb/IIIa inhibitor include patients with evidence of ongoing ischemia despite therapy with aspirin + P2Y12 inhibitor for whom invasive approach is planned; and patients who have high-risk features during angiography such as large thrombus burden or intraprocedural thrombotic complication, particularly if they have not received prasugrel or ticagrelor.
  3. For those patients with a history of GI bleeding, drugs that reduce the risk of recurrent bleeding (e.g., PPIs) should be given.

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