We recommend clopidogrel 75 mg daily for at least 1 month in addition to ASA 81 mg daily in patients with STEMI who were managed with either fibrinolytic therapy or no reperfusion therapy (Strong, High).

We suggest that clopidogrel can be continued for 12 months (Conditional, Low).

We recommend either prasugrel 10 mg daily or ticagrelor 90 mg twice daily over clopidogrel 75 mg daily for 12 months in addition to ASA 81 mg daily after primary PCI (Strong, Moderate).

We recommend clopidogrel 75mg daily for 12 months in addition to ASA 81 mg daily after primary PCI in patients who are not eligible for prasugrel or ticagrelor (Strong, Moderate).

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 STEMI treated with PCI (Strong, Moderate).

We recommend avoiding prasugrel in patients with previous TIA or stroke and using a 5-mg dose if required in patients aged 75 years or older or weight less than or equal to 60 kg (Strong, Low).

Values and Preferences

• These recommendations place greater emphasis on reduction of major cardiovascular events vs an increase in bleeding.
• These also account for the clinical setting where 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.