Clopidogrel Administration of clopidogrel with aspirin was superior to administration of aspirin alone in reducing the incidence of cardiovascular death and nonfatal MI or stroke both acutely and over the following 11 months.289,296 There was a slight increase in major bleeding events with clopidogrel, including a nonsignificant increase in life-threatening bleeding and fatal An initial loading dose of 300 mg to 600 mg is rec- A 600-mg loading dose results in a greater, more rapid, and more reliable platelet inhibition compared with a 300-mg loading dose.301 Use of clopidogrel for patients with NSTE-ACS who are aspirin intolerant is based on a study Table 7. Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI Recommendations Dosing and Special Considerations COR LOE References Aspirin Non enteric-coated aspirin to all patients promptly after presentation Aspirin maintenance dose continued indefinitely 81 mg/d-325 mg/d* I A 288 290, inhibitors Clopidogrel loading dose followed by daily maintenance dose in patients unable to take aspirin 75 mg I B 291 inhibitor, in addition to aspirin, for up to 12 mo for patients treated initially with either an early invasive or initial ischemia- guided strategy: Clopidogrel Ticagrelor* 300-mg or 600-mg loading dose, then 75 mg/d I B 180-mg loading dose, then 90 mg BID inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) continued for at least 12 mo in post PCI patients treated with coronary stents N/A I B Ticagrelor in preference to clopidogrel for patients treated with an early invasive or ischemia-guided strategy N/A IIa B 293, 294 GP IIb/IIIa inhibitors GP IIb/IIIa inhibitor in patients treated with an early invasive strategy and DAPT with intermediate/high-risk features (eg, positive troponin) Preferred options are eptifibatide Parenteral anticoagulant and fibrinolytic therapy SC enoxaparin for duration of hospitalization or until PCI is performed 1 mg/kg SC every 12 h (reduce dose to 1 mg/kg/d SC in patients with CrCl Initial 30 mg IV loading dose in selected patients Bivalirudin until diagnostic angiography or PCI is performed in patients with early invasive strategy only Loading dose 0.10 mg/kg loading dose followed by 0.25 mg/kg/h Only provisional use of GP IIb/IIIa inhibitor in patients also treated with DAPT I B SC fondaparinux for the duration of hospitalization or until PCI is performed 2.5 mg SC daily I B 312 314 Administer additional anticoagulant with anti-IIa activity if PCI is performed while patient is on fondaparinux N/A I B 313 315 IV UFH for 48 h or until PCI is performed Initial loading dose 60 IU/kg (max 4000 IU) with initial infusion 12 IU/kg/h (max 1000 IU/ h) Adjusted to therapeutic aPTT range I B 316 322 IV fibrinolytic treatment not recommended in patients with NSTE-ACS N/A III: Harm A 93, 329 See Section 5.1.2.1 for recommendations on antiplatelet/anticoagulant therapy at the time of PCI and Sections 6.2.1 and 6.3 for recommendations on posthospital therapy. 