By Professor Juan Tamargo, Madrid, Spain
The new update of the guideline for the management of patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) of the the American Heart Association and the American College of Cardiology Foundation recommended prasugrel, ticagrelor, or clopidogrel as an option for combination with aspirin in dual anti-platelet therapy, with level B evidence for both newer agents compared with level A for clopidogrel. The recommended doses are 180 mg ticagrelor before or at the time of PCI, with a 90-mg bid maintenance dose for at least 1 year.
The guideline did not recommend one agent over another because there have been no head-to-head trials of the three agents in the same clinical trial, but emphasized the increased potential bleeding risk with the newer agents over clopidogrel.
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012;60:645-81