Читать книгу Practical Cardiovascular Medicine - Elias B. Hanna - Страница 114

1 Aspirin 325 mg upon presentation.

2 ADP-receptor antagonist is loaded at the time of PCI, or in the emergency room before catheterization if STEMI diagnosis is certain.75 Even prasugrel may be loaded before catheterization in STEMI. Yet, ATLANTIC trial failed to show a benefit of pre-cath loading vs. loading during PCI.76Ticagrelor and prasugrel are preferred as they further reduce ischemic events compared to clopidogrel, particularly in STEMI.

3 Upstream unfractionated heparin (UFH) in the ED (60 units/kg, up to a maximum dose of 4000 units).

4 During PCI:UFHBivalirudin vs. UFH: initial studies suggested lower bleeding with bivalirudin, but these studies were flawed by an unbalanced GPI use with UFH. A radial-access study with balanced and limited GPI use (SWEDEHEART) showed an ischemic and bleeding risk identical to UFH.77 Also, bivalirudin may be associated with a higher risk of acute stent thrombosis than UFH, which is reduced by 1-4 hours of high-dose bivalirudin post-PCI. Except for this optional brief infusion of bivalirudin, anticoagulants are stopped after PCI.GPI, in conjunction with either UFH or bivalirudin, is reserved for bailout use during PCI (large thrombus burden, thrombotic complications, or no reflow) (class IIa).78 In contemporary trials, ~15% of STEMI patients require the use of GPI.