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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article reviews the main data regarding ticagrelor, prasugrel, and clopidogrel therapy in patients with ST-segment elevation myocardial infarction (STEMI). Additional topics include new evidence regarding the timing of antiplatelet loading, managing antiplatelet therapy in patients undergoing CABG surgery, as well as new strategies for managing atrial fibrillation and concomitant coronary artery disease and acute coronary syndromes.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECoronary Artery Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EArrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EPierluigi Tricoci, MD, MHS, PhD, Duke University Medical Center, Durham, North Carolina, USA, reviewed the main data regarding ticagrelor, prasugrel, and clopidogrel therapy in patients with ST-segment elevation myocardial infarction (STEMI).\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe CLARITY trial [Sabatine MS et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2005] established that the addition of clopidogrel to aspirin plus fibrinolytics improves the patency rate of the infarct-related artery and reduces ischemic complications (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). This study also reported benefit with clopidogrel pretreatment, despite its slower onset of action vs other antiplatelet therapies [Sabatine MS et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2005].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Clopidogrel vs Placebo in Patients with STEMI\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1540768496\u0022 data-figure-caption=\u0022Clopidogrel vs Placebo in Patients with STEMI\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15361\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EClopidogrel vs Placebo in Patients with STEMI\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003ECV, cardiovascular; MI, myocardial infarction.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EAdapted from \u003Cem\u003ENew Engl J Med.\u003C\/em\u003E Sabatine MS et al, Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation, 352, 1179\u20131189. Copyright \u00a9 2005. Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EShortcomings of clopidogrel include a delayed bio-availability in patients with STEMI [Heestermans AA et al. \u003Cem\u003EThromb Res.\u003C\/em\u003E 2008] and genetic variability that affects metabolism and platelet function [Holmes MV et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2011]. Some evidence suggests that doubling the dose may help overcome these negative qualities [Mehta SR et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2010]. Advantages for prasugrel over clopidogrel include less susceptibility to genetic variation and drug-drug interactions, and more rapid, more consistent, and higher levels of platelet inhibition [Wiviott SD et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2010]. The TRITONTIMI 38 trial [Wiviott SD et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2007] showed that prasugrel was more effective than clopidogrel in reducing cardiovascular (CV) death, MI, stroke, and stent thrombosis but at a cost of increased bleeding.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003ETicagrelor can achieve a faster and longer antiplatelet effect compared with clopidogrel, and its maintenance dose sustains greater platelet inhibition throughout time [Storey RF. \u003Cem\u003EEur Heart J Suppl\u003C\/em\u003E. 2008]. Compared with clopidogrel, ticagrelor leads to greater reductions in mortality, MI, stroke, and stent thrombosis without increasing the total major bleeding risk [Wallentin L et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009]. The platelet inhibition achieved with ticagrelor is similar to that of prasugrel [Parodi G et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2013].\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EBoth ticagrelor and prasugrel have been shown to be superior to clopidogrel, and they should be the agents of choice in patients with STEMI who are treated with percutaneous coronary intervention (PCI). In the PLATO trial, ticagrelor also reduced CV death.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003ESteen Husted, MD, DSc, Medical Department, Hospital Unit West, Herning, Denmark, presented new evidence regarding the timing of antiplatelet loading in patients presenting with acute MI.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EThe 2014 European Society of Cardiology (ESC)\/European Association for Cardio-Thoracic Surgery (EACTS) guidelines on myocardial revascularization [Windecker S et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014] recommend that patients undergoing PCI receive a combination of aspirin plus a P2Y\u003Csub\u003E12\u003C\/sub\u003E receptor blocker as early as possible before angiography and a parenteral anticoagulant to lower the risk of stent thrombosis.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EPretreatment (prior to arrival at the hospital or upstream of coronary angiography) is appropriate for patients with STEMI because the diagnosis is often clear, the risk of urgent surgery is low, and oral antiplatelet therapy requires several hours to reach efficacy. The ATLANTIC study [Montalescot G et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2014] assessed outcomes following antiplatelet therapy administered in the ambulance compared with in-hospital administration (time difference of 31 minutes) in patients having STEMI with intended primary PCI. Coprimary end points were the percentage of patients reaching TIMI flow grade 3 in the infarct-related artery at initial angiography or achieving \u2265 70% STE resolution pre-PCI. There was no significant difference in the components of the primary end point (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E), or in the occurrence of major adverse cardiac events (MACEs) or non-coronary artery bypass graft (CABG)-related bleeding events.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022No TIMI Flow Grade 3 in Infarct-Related Artery\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1540768496\u0022 data-figure-caption=\u0022No TIMI Flow Grade 3 in Infarct-Related Artery\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15362\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003ENo TIMI Flow Grade 3 in Infarct-Related Artery\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-3\u0022\u003ENS, nonsignificant; PCI, percutaneous coronary intervention; TIMI, Thrombolysis in Myocardial Infarction.\u003C\/q\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-4\u0022\u003EData source: Montalescot G et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2014. Reproduced with permission from S Husted, MD, DSc.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-12\u0022\u003EThere was, however, a significant reduction (\u003Cem\u003EP\u003C\/em\u003E = .0225) in definite stent thrombosis up to 30 days.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EAdministration of prehospital ticagrelor shortly before PCI in patients with ongoing STEMI is safe and reduces the risk of post-PCI stent thrombosis; it does not improve pre-PCI coronary reperfusion. In patients with non-STE acute coronary syndrome (NSTE-ACS), in which diagnostic uncertainty is frequent, Dr Husted recommends starting therapy with ticagrelor when diagnosis is confirmed.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EPretreatment with clopidogrel significantly (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) reduces the absolute risk of MACEs but not death in patients undergoing PCI (STEMI and NSTE-ACS) [Bellemain-Appaix A. \u003Cem\u003EJAMA\u003C\/em\u003E. 2012]. Clopidogrel may be useful in patients waiting for angiography. In the ACCOAST trial [Montalescot G et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2013], prasugrel at the time of diagnosis compared with after angiography (time difference, 4 hours) in patients with NSTE-ACS did not reduce any of the primary outcome factors, but it significantly (\u003Cem\u003EP\u003C\/em\u003E = .006) increased the rate of TIMI major bleeding. As a result, prehospital treatment of patients with NSTE-ACS with prasugrel is not supported by the current data. In patients with NSTE-ACS, pretreatment before angiography may be beneficial if patients have to wait for the angiography or if the P2Y\u003Csub\u003E12\u003C\/sub\u003E agent used has a slow onset of action.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003ESven Wassmann MD, Department of Cardiology, Isar Heart Center, Munich, Germany, previewed new strategies for managing atrial fibrillation (AF) and concomitant coronary artery disease (CAD) and acute coronary syndromes (ACSs).\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EPatients with AF with CAD, stents, or ACS often require treatment with both antiplatelet and anticoagulant therapy to reduce CV events and the risk of stroke. This approach, however, significantly increases the incidence of major bleeding, with longer duration of therapy being associated with increased risk [Hansen ML et al. \u003Cem\u003EArch Intern Med.\u003C\/em\u003E 2010]. Thus, reducing the time of triple therapy is an important step. The 2012 focused update of the ESC guidelines for the management of AF [Camm AJ et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2012] recommends treating with triple therapy in the early phase followed by dual therapy in the later phase (after 6 months) in patients with low bleeding risk. After 12 months, only anticoagulation treatment should be used. In patients with high bleeding risk, the time of triple therapy can be reduced to 1 month.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EThe ISAR-TRIPLE trial [\u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00776633\u0026amp;atom=%2Fspmdc%2F14%2F42%2F25.atom\u0022\u003ENCT00776633\u003C\/a\u003E] compared triple therapy for 6 months versus 6 weeks and found no significant (\u003Cem\u003EP\u003C\/em\u003E = .63) difference regarding the combined end point of death, MI, stent thrombosis, stroke, or major TIMI bleeding [Sarafoff N et al. TCT 2014].\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EUsing dual therapy from the start is another approach. The WOEST study [Dewilde WJ et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2013] reported that the use of a vitamin K antagonist (VKA) oral anticoagulant (OAC) plus clopidogrel (dual therapy) significantly (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .0001) reduced bleeding compared with triple therapy (OAC plus clopidogrel plus aspirin) with no increase in the rate of thrombotic events in stented patients with AF.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003ENon-VKA OACs appear to be associated with a lower bleeding risk, particularly at low doses [Ruff CT et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2014]. In a subset analysis of the RE-LY trial [Dans Al et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2013], concomitant antiplatelet drugs appeared to increase the risk for major bleeding without affecting the advantages of dabigatran over warfarin. Dabigatran, however, appeared to have a lower absolute risk of bleeding with lower doses.\u003C\/p\u003E\u003Cp id=\u0022p-20\u0022\u003ECurrent joint guidelines on the management of patients with AF and ACSs\/stents [Lip GY et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014] provide new guidance on treating these patients with OACs and antiplatelet therapy (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Definitive clinical studies to document these consensus statements are in process.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15364\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15364\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15364\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-21\u0022 class=\u0022first-child\u0022\u003EESC\/EHRA\/EAPCI\/ACCA\/APHRS 2014 Consensus Document for Management of Antithrombotic Therapy in Patients With Atrial Fibrillation\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-24\u0022\u003EIn patients with NSTE-ACS, the ESC\/EACTS guidelines recommend a revascularization strategy based on the individual patient\u0027s clinical status and disease severity (\u003Ca id=\u0022xref-fig-3-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E) [Windecker S et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cdiv id=\u0022F3\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F3.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Algorithm for Preoperative Management of Patients Under Dual Antiplatelet Therapy\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1540768496\u0022 data-figure-caption=\u0022Algorithm for Preoperative Management of Patients Under Dual Antiplatelet Therapy\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 3.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F3.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F3.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 3.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/25\/F3.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15363\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 3.\u003C\/span\u003E \n            \u003Cp id=\u0022p-25\u0022 class=\u0022first-child\u0022\u003EAlgorithm for Preoperative Management of Patients Under Dual Antiplatelet Therapy\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-5\u0022\u003EWindecker S et al. 2014 ESC\/EACTS Guidelines on myocardial revascularization. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014;35:2541\u20132619. With permission from European Society of Cardiology.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-26\u0022\u003EPiroze M. Davierwala, MD, Heart Center, University of Leipzig, Leipzig, Germany, discussed managing antiplatelet therapy in patients undergoing CABG surgery.\u003C\/p\u003E\u003Cp id=\u0022p-27\u0022\u003ETreatment with single and dual antiplatelet therapy (DAPT) affects early and late outcomes, but despite multiple studies [Au AG et al. \u003Cem\u003EAm J Med.\u003C\/em\u003E 2012; Smith PK et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2012; Held C et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2011; Nijjer SS et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2011; Bybee KA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2005], there is still no definitive answer concerning the safety of DAPT in the context of CABG. Nor is the optimal bleeding-thrombotic risk balance known. Ongoing trials may help to answer these questions.\u003C\/p\u003E\u003Cp id=\u0022p-28\u0022\u003EPrevention of bleeding is important because bleeding and\/or blood transfusion is independently associated with an increased risk of serious complications and death [Koch CG et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E. 2006; Rao SV et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E. 2005]. All patients should be assessed for bleeding risk, and preoperative interventions that may reduce the risk of bleeding should be taken. Proper management of antiplatelet therapy prior to surgery is critical (\u003Ca id=\u0022xref-fig-3-2\u0022 class=\u0022xref-fig\u0022 href=\u0022#F3\u0022\u003EFigure 3\u003C\/a\u003E) and should be a multidisciplinary effort [Sousa-Uva M et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014]. Bridging strategies should be adopted for patients at high risk for thrombosis [Sousa-Uva M et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2014]. It is reasonable to use platelet function monitoring to determine the timing of surgery rather than an arbitrary period of delay, although this has not yet been tested prospectively [Janssen PW et al. \u003Cem\u003EBlood Rev.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-29\u0022\u003EIn general, more attention should be directed to blood conservation and the judicious use of red blood cells. Off-pump CABG, small circuits, antifibrinolytic drugs, erythrocyte salvage devices (cell savers), and meticulous surgical hemostasis and technique can all contribute to reduce blood loss.\u003C\/p\u003E\u003Cp id=\u0022p-30\u0022\u003EAfter CABG, all patients should receive aspirin, and patients with ACS should continue on DAPT (aspirin plus ticagrelor or clopidogrel) for 12 months.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/42\/25.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzokeq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzokeq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzokeq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}