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Home | Articles | Cardiac | Anti-Platelet Therapy in Coronary Heart Disease

Anti-Platelet Therapy in Coronary Heart Disease

Last updated 22nd November 2023

The GJNH consultant cardiologists have recently agreed to use prasugrel as the P2Y12 inhibitor of choice used alongside aspirin in ACS, replacing ticagrelor.  This changes our advice on antiplatelet therapy in coronary heart disease as follows:

Antiplatelet Therapy Prior to Coronary Angiography

ST-Elevation Myocardial Infarction (STEMI) / High Risk NSTEMI (HRNSTEMI)

  1. Patients will be loaded with 300mg Aspirin and 300-600mg Clopidogrel by Scottish Ambulance Service or in A+E prior to transfer to GJNH. On advice from GJNH patients may be loaded with 60mg Prasugrel prior to transfer in their base hospital, alongside Aspirin.

STEMI/NSTEMI with Thrombolysis Advised by GJNH

  1. Patients will be loaded with 300mg Aspirin and 300mg Clopidogrel and treated with tissue plasminogen activators for thrombolysis.
  2. They may then receive Prasugrel as below post PCI, alongside Aspirin.
  3. Prasugrel should not be commenced in the first 24 hours following thrombolysis.

Non ST-Elevation Myocardial Infarction (NSTEMI)

  1. Patients will be loaded with 300mg Aspirin and 300-600mg Clopidogrel, then maintained on 75mg daily of Aspirin and Clopidogrel until transfer to GJNH.

Antiplatelet Therapy Following Angiography

Patients Who Have Undergone PCI

  1. Patients should be loaded with Prasugrel 60mg followed by a maintenance dose of 10mg daily unless:
  2. Patients with CVA/TIA history – Prasugrel is contraindicated. Clopidogrel should be continued at 75mg daily.
  3. Patients ≥75 years old or <60kg – Prasugrel can be continued at the discretion of a consultant cardiologist at a dose of 5mg daily.
  4. Patients with an indication for anticoagulation – Continue Clopidogrel until discussion with cardiologist.
  5. Duration of Prasugrel will be 6 months post PCI unless otherwise specified by the cardiologist. Longer duration – up to 12 months – can be considered where thrombosis risks outweigh bleed risks. Aspirin should continue lifelong.
  6. Prasugrel can be loaded on the same day as the loading dose of Clopidogrel.

Patients for Whom Medical Therapy is Indicated

  1. Patients will remain on Clopidogrel.  Duration will be specified by the cardiologist.  
  2. Aspirin should continue lifelong.

Patients for Whom Revascularisation with Coronary Artery Bypass Grafts (CABG) is Indicated

  1. Patients will remain on Aspirin and Clopidogrel. Clopidogrel should ideally be held for one week prior to surgery.
  2. Following CABG and removal of epicardial wires, chest drains and central line, patients should be recommenced on Clopidogrel for 12 months unless otherwise specified by the surgeon.

Patients Admitted on Ticagrelor

  1. Patients who have been discharged in the period between November 2022 and November 2023 may be admitted on Ticagrelor from previous intervention. This should be continued until the point of coronary angiography.
  2. It will then be at the discretion of the interventional cardiologist as to whether patients continue on Ticagrelor or are loaded with Prasugrel. This will be reviewed on a patient-by-patient basis.
  3. Aspirin should continue lifelong.

Treatment with PCI Following Cardiac Arrest

  1. Patients should remain on Aspirin and Clopidogrel. Aspirin can be dispersed in water while Clopidogrel can be crushed and given via NG tube.
  2. As the patient improves and oral route becomes available, consideration can be given to switching therapy to Prasugrel.

Elective Patients

Treatment with PCI

  1. Patients should continue with Clopidogrel for 6 months unless otherwise specified by the cardiologist. Aspirin should continue lifelong.

Medical Management

  1.  Patients should continue with Clopidogrel with duration specified by the cardiologist.
  2. Aspirin should continue lifelong.

Combination Antiplatelet and Anticoagulant Therapy

  1. This is associated with a significantly higher risk of major haemorrhage than either agent alone, without offering proven benefit in reducing ischaemic or thrombo-embolic events except in patients with metallic prosthetic heart valves.

Patients on DOAC/Warfarin Who Require Antiplatelet Agent

  1. Lower risk patients (e.g. AF with low CHADSVASC score, DVT >3 months previously) who develop a need for DAPT should stop DOACWarfarin or receive triple therapy for as short a time as possible. If stenting is necessary in such patients consideration should be given to preferring a bare metal stent
  2. Higher risk patients (e.g. AF with high CHADSVASC score, recent PE) developing ACS require specialist advice and should be considered for triple therapy

Patients on Antiplatelet Therapy Who Require DOAC/Warfarin

  1. If stable vascular disease on single antiplatelet therapy and develops AF/DVT then discontinue for duration of warfarin
  2. If patients have unstable vascular disease (e.g. recent ACS or stent) and are taking DAPT, DOAC/warfarin should be commenced cautiously with close monitoring. Possible discontinuation of antiplatelet agents earlier than planned should be discussed with an interventional cardiologist.
  3. Some high thrombotic risk patients with low inherent bleeding risk may warrant short term triple therapy, but each case should be considered on its own merits with a risk:benefit assessment.

Notes on Prasugrel

  1. Prasugrel is a 3rd generation P2Y12 inhibitor, that inhibits platelet activation and aggregation through irreversible binding to ADP receptors on platelets.
  2. Prasugrel will only be used in patients who have received percutaneous coronary intervention (PCI). In patients awaiting angiography or for whom medical therapy is indicated, clopidogrel will be used.
  3. The rationale for the change is the ISAR-REACT 5 Trial. This found that among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups.
  4. Prasugrel is also more cost effective than Ticagrelor, as it is now available as a generic product whilst Ticagrelor remains on patent.

Content by Chris Isles from GJNH Guidance