Glycoprotein IIb/IIIa Receptor Antagonists

1. Treatment with glycoprotein IIb/IIIa receptor antagonists may be started at the time of primary PCI (with/without stenting) in selected patients with STEMI: abciximab (Class IIa, LOE: A) OR tirofiban or eptifibatide (Class IIa, LOE: B).

2. The usefulness of glycoprotein IIb/IIIa receptor antagonists as part of a preparatory pharmacological strategy for patients with STEMI before their arrival in the cardiac catheterization laboratory for angiography and PCI is uncertain (Class IIb, LOE: B).

Thienopyridines

1. A loading dose of thienopyridine is recommended for STEMI patients for whom PCI is planned: at least 300–600 mg of clopidogrel as early as possible before or at the time of primary or nonprimary PCI [Class I, LOE: C] OR prasugrel 60 mg as soon as possible for primary PCI (Class I, LOE: B).

2. Patients who receive a bare metal (BMS) or drug-eluting (DES) stent during PCI for acute coronary syndrome should be given clopidogrel 75 mg daily (Class I, LOE: B) or prasugrel 10 mg daily (Class I, LOE: B) for at least 12 months. If the risk of morbidity due to bleeding outweighs the anticipated benefit that is afforded by thienopyridine therapy, earlier discontinuation should be considered (Class I, LOE: C).

Thienopyridines

1. Prasugrel is not recommended as part of a dual antiplatelet therapy regimen in STEMI patients with a prior history of stroke and transient ischemic attack for whom primary PCI is planned (Class III, LOE: C).

2. Intensive glucose control.

3. It is reasonable to use an insulin-based regimen to achieve and maintain glucose levels <180 mg/dL while avoiding hypoglycemia for patients with STEMI with either a complicated or uncomplicated course (Class I, LOE: B).

4. Stents.

5. A DES may be used as an alternative to a BMS for primary PCI in STEMI (Class IIa, LOE: B).

6. A DES may be considered for clinical and anatomical settings in which the efficacy/safety profile appears favorable (Class IIb, LOE: B).

Angiography in Patients with Chronic Kidney Disease (CKD)

1. Appropriate contrast agents during angiography or PCI in patients with CKD now include both isosmolar (Class I, LOE: A) and a low-molecular-weight contrast medium other than ioxaglate or iohexol (Class I, LOE: B).

2. Fractional flow reserve (FFR).

3. It is reasonable to use FFR (Class IIa, LOE: A) or Doppler velocimetry (Class IIa, LOE: C) to assess the effects of intermediate coronary stenoses (30% to 70% luminal narrowing) in patients with anginal symptoms.

4. Routine assessment with FFR or Doppler ultrasonography to assess angiographic disease severity in concordant vascular distribution in patients with angina and a positive, unequivocal noninvasive functional study is not recommended (Class III, LOE: C).

PCI for Unprotected Left Main Coronary Artery Disease

1. PCI of the left main coronary artery using stents as an alternative to coronary artery bypass graft (CABG) may be considered in patients with anatomical conditions that are associated with low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes (Class IIb, LOE: B).

2. Timing of angiography and antiplatelet therapy in UA/ NSTEMI.

3. Patients with definite or likely unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) who are selected for an invasive approach should receive dual antiplatelet therapy (Class I, LOE: A). Aspirin should be initiated on presentation (Class I, LOE: A). Either clopidogrel (before or at the time of PCI) (Class I, LOE: A) OR prasugrel (at the time of PCI) (Class I, LOE: B) is recommended as a second antiplatelet agent.

It is reasonable for initially stabilized high-risk patients with UA/NSTEMI Global Registry of Acute Coronary Events (GRACE) score >140 to undergo an early invasive strategy within 12 to 24 hours of admission. For patients who are not at high risk, an early invasive approach is also reasonable (Class IIa, LOE: B).