Selecting the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention

Figures & data

Figure 1 The TIMI, PURSUIT, and GRACE risk scores.

Abbreviations: CAD, coronary artery disease; CCS, Canadian Cardiovascular Society; CHF, congestive heart failure; MI, myocardial infarction; PCI, percutaneous coronary intervention.

Table 1 Antithrombotic agents commonly administered to patients with acute coronary syndrome undergoing percutaneous coronary intervention

Antiplatelet

Aspirin

Thienopyridine (clopidogrel)

Platelet glycoprotein IIb/IIIa inhibitors

Anticoagulant

Indirect thrombin inhibitors

Unfractionated heparin

Low molecular weight heparin

Direct thrombin inhibitor (bivalirudin)

Factor Xa inhibitor (fondaparinux)

Table 2 Key considerations in selecting the optimal antithrombotic regimen for an individual patient

Risk of recurrent ischemic event	Consider
	TIMI risk score
	GRACE risk score
	PURSUIT risk score
Risk of major bleeding	Consider
	CRUSADE bleeding score
Clopidogrel pretreatment	Yes or no
	If yes, determine timing and dose of administration prior to PCI procedure
Enoxaparin pretreatment	Yes or no
	If yes, determine timing and dose of administration prior to PCI procedure
Renal insufficiency	Yes or no
	If yes, follow recommended renal dosinga
Heparin-induced thrombocytopenia	Yes or no
	If yes, tailor regimen accordingly, use bivalirudin in place of heparin

^a integrilin, fondaparinux and enoxaparin should be avoided in patients with severe renal insufficiency (creatinine-clearance ≤30 mL/min).

Abbreviations: CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines;¹¹² GRACE, Global Registry of Acute Coronary Events;¹¹⁰ PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy;¹¹¹ TIMI, Thrombolysis in Myocardial Infarction.¹⁰⁹

Figure 2 Algorithm for selecting the optimal antithrombotic regimen incorporating cardiac risk, bleeding risk, and clopidogrel pretreatment. In this algorithm it is assumed that all patients have received aspirin.

*If bivalirudin is used, a loading dose of clopidogrel should be given as soon as possible in the cardiac catheterization laboratory to decrease the risk of subacute stent thrombosis.

BoersmaEPieperKSSteyerbergEWPredictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT InvestigatorsCirculation2000101222557256710840005

 PubMed Web of Science ®Google Scholar

AntmanEMCohenMBerninkPJThe TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision makingJAMA2000284783584210938172

 PubMed Web of Science ®Google Scholar

EagleKALimMJDabbousOHA validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registryJAMA2004291222727273315187054

 PubMed Web of Science ®Google Scholar

HillisLDLangeRAOptimal management of acute coronary syndromesN Engl J Med2009360212237224019458369

 PubMed Web of Science ®Google Scholar