Prasugrel, in a 10-mg daily maintenance dose, is rea- sonable after PCI.260,262 (Level of Evidence: B) Class III: Harm 1. Prasugrel should not be administered to patients with a history of prior stroke or transient ischemic (Level of Evidence: B) Patients with STEMI should receive clopidogrel at the time of administration of a fibrinolytic agent as a routine part of a pharmacological reperfusion strategy (Section 5.1). Clopido- grel then should be continued in uninterrupted fashion through and after PCI. The optimal loading dose of clopidogrel before or at the time of PCI in patients who may not have received it previously with fibrinolytic therapy is not known. In the CLARITY-TIMI 28 (Clopidogrel as Adjunctive Reperfusion Therapy Thrombolysis In Myocardial Infarction 28) trial,331 PCI was performed 2 to 8 days after fibrinolysis in about half of the enrolled patients, and open-label clopidogrel (300-mg loading dose, 75-mg maintenance dose) was administered after diagnostic angiography in patients undergoing infarct artery stenting. Treatment with clopidogrel significantly reduced the incidence of cardiovascular death, MI, or stroke (major sec- ondary composite endpoint) after PCI. In addition, there was no significant increase in the rates of TIMI major or minor bleeding with clopidogrel treatment. A subset of patients with STEMI in the TRITON-TIMI 38 trial received fibrinolytic therapy >24 hours (for fibrin-specific agents) or >48 hours (for non fibrin-specific agents) before PCI. In this subset, the use of prasugrel compared to clopidogrel was associated with a significantly lower rate of the primary composite endpoint of cardiovascular death, nonfatal MI, or nonfatal stroke (HR: TIMI major bleeding unrelated to CABG.262 Accordingly, pra- sugrel (60-mg loading dose) may be used as an alternative to clopidogrel in patients with STEMI who undergo delayed PCI after administration of a fibrinolytic agent. 6.4.2. 