We recommend ASA 81 mg daily indefinitely in all patients with NSTEACS (Strong, High).

We recommend ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily in patients with moderate to high risk NSTEACS (Strong, High).

We recommend prasugrel 10 mg daily over clopidogrel 75mg daily for 12 months in addition to ASA 81mg daily in P2Y12 inhibitor-naive patients with NSTEACS after their coronary anatomy has been defined and PCI planned (Strong, High).

We recommend avoiding prasugrel in patients with previous TIA or stroke or in patients who are not treated with PCI. Except in patients with a high probability of undergoing PCI, we recommend avoiding prasugrel before the coronary anatomy has been defined (Strong, Moderate).

We recommend clopidogrel 75 mg once daily for 12 months in addition to ASA 81 mg daily in patients with NSTEACS managed with either PCI, CABG, or medical therapy and who are not eligible for ticagrelor or prasugrel (Strong, High).

We recommend that in patients in whom clopidogrel is to be used, a higher maintenance dose of 150 mg daily be considered for the first 6 days in patients with NSTEACS treated with PCI (Strong, Moderate).

Values and Preferences

• These recommendations place greater emphasis on reduction of major cardiovascular events and stent thrombosis versus an increase in bleeding complications.
• They also take into account the clinical setting under which each of the antiplatelet drugs were evaluated and the more reliable bioavailability of prasugrel and ticagrelor compared with clopidogrel.

Practical tips

• In patients receiving dual antiplatelet therapy (DAPT), we suggest using ASA 81 mg daily.
• Ticagrelor can be used in patients managed with either PCI, CABG, or medical therapy alone, whereas prasugrel should be used only in patients undergoing PCI.
• In patients 75 years of age or older or weight less than or equal to 60 kg prasugrel 5 mg daily could be considered.